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'''.; \ —,) q .... \ 1 • u \ ‘, ,, .. 1 J HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two -year period shall not be considered a home owner." The building department for the City of Northampton wants person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations The inspection procea &requires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill), sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper --- - - - - -- permit- in -conjunction_to the_building permitissued, and that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents 1 "Mk ►�— $ Office of Investig,atiorts ii =.., I� +i= ' 600 Washington Street =41 Boston, MA 02111 MILAN, www.mass gov /dia • Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians,PIumb.ers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 'Rc')r_7:, CA Afk1 ?.1(J 1 Address: 7 L AY J IAC1 IJ L 0 1 - \ C ity /State /Zip: Rt■\I� ! rfA 0153) Phone. #: 413 5 31 `'� c 1 1 Are you an employer? Check the appropriate bo Type of project (required): �' 1. Cil I am a employer with 4. 0 I am a general contractor and I r 6. ❑New construction employees (full and/or p time).* have hired the sub- contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have. no P^lsloyees These sub - contractors have. 8. 0 Demolition working for me in any ca P aci employee and have workers' capacity. t 9. 0 Building addition [No workers' comp. insurance comp.:rnsurance.__ required] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.0 1 am a -homeo-waer- datng- all -work- — _o_facers_iave xeiciszdiheir El_klumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance requited. }. *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such= tContractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees. If the sub- contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site __Li fz ormatwn Insurance Company Name: I 1 -A( . 1� � © ��. , \� Policy # or Self-ins. L #: G 5 V �� ' g 1 - 1 - u t ' N\04,1-,* () k � - Expiration Date: / i 11 t D Job Site Address: t '1 E'S 8 r (62C-, pi) cit /State /zip:. Mz kA�1 ''i o P i' -A Attach a copy of the workers' compensati policy declaration page (showing the policy number and iration date). Failure to secure coverage, as required under Section of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one :year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification t nd . enuties o , e 'u that the information rovided..abave� rue.and_correct._ I do herebyce le F ep ' fP '7 �' .f p - -- S J/e� 0 s . a e . Phone ##: 6 1/3 531. T OffiCial use oiffy. Do not write iii lid k area, to be Eompre by city or town OfficiaL City or Town: Permit/License # Issuing Authority (circle one): F- Board of Health 2. Building Department 3. City/Town Clerk 4: Electrical inspector 5. Plumbing Inspector _ _ 6. Other r Contact Person: Phone #: t SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Constructio �ir� Not Applicable ❑ Name of License Holder : 1 v,'R, J\)i , License Number _7 LA \(( uQQ(> Dk 051541 Address Expiration Date \—\0\kclk s3 fr1 f' O\S'L\ Signature Telephone I /OS/10 C r ' 4 1l3 531 -i-13 9_Req#ste.d €tomd.fmtirov i eiit ntr for . ., , . * y. 4._.,,. .g .,, Not Applicable ❑ ?ftrk Ara,Z1.o1\i tS300 Company Name Registraf n Number LP., SIB DTZ, i iloi l Address (n� Expiration Date 1 - - \ \ \R �1/� / ICI 1 ' ► =, Telephone `-1� 13 5 � /) SECTION '10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6» Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes e gii No ❑ The_current_exemption for' homeowners" was extended to include Qwner- occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two - year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference'to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of 1 o ampton • r • tnances, a - e .n .' Loea'1`" _ . - - r - -o- , , . - s-General- Laws- Annotated. Homeowner Signature c L J SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition .M Replacement Windows Alteration(s) n I Roofing ❑ Or Doors E Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [C] Siding [Dj Other [D] Brief Description of Proposed I n i Work: LA% t LJT' al Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative . Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa 1f14evit ousa, it di i iodid aidsting : ousii q complete thelalieiu iici: a. Use of building : One Family X Two Family Other b. Number of rooms in each family unit: 5 Number of Bathrooms 1 ry } I' c. Is there a garage attached? v • d. Proposed Square footage of new construction. 570 Dimensions 1 q x 30 e. Number of stories? . .61 f. Method of heating? r 1 1 BAS [} fSpfiZT Fireplaces or Woodstoves j Number of each I g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction 1/0("\C FRAIY\e l i. Is construction within 100 ft of wetlands? Yes V No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade E Y 1 t 1 ' k. Will building conform to the Building and Zoning regulations? k. Yes No . L Septic Tank City Sewer Private well City water Supply V SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN , OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, eUG 1_ o G , as Owner of the subject property (p ( I � � �rl }� � hereby authorize l C�bGn� J/ \� �l! o J V \ to an my behalf, in all matters relative to work authorized by this building permit apglicati n. W /ir . ` $l 19 Si. ature of Owner / Date I, 2X3v J¼' c, ,,,,,N , as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed un the pains and pe alties perjury. o G t Z�Z ® Print Name 1FP - -L Signature of •wner /Ag- t Date II , Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage _._ . ._.. ___ _ .. _.._ _ Setbacks Front Side L: R. L:i R:1_ . � _ Rear ... Building Height Bldg. Square Footage" 7 -7 % - --- M----• r" Open Space Footage % (Lot area minus bldg & paved �..w �� Sen parking) # of Parking Spaces - - Fill: 1 _ ..... w.. .. ... ., r .. -a.. (volume & Location) ?i ._.._,_._______ ,_,_.._....� _____„ . _..... A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO J, DONT KNOW 0 YES IF YES, date issued:! I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Pagel i and /or Document #, B. Does the site contain a brook, body of water or wetlands? NO 3 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D "`Are tl`iere any proposed c tKanges to or ad rtlons o - sig -ii intended -he property ? YES 0 NO 0 IF YES, describe size, type and location: E. WA the construction activity disturb (clearing, grading excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO V A IF YES, then a Northampton Storm Water Management Permit from the DPW is required. a Ito r 5 iiiigi. �� 3t � ; f e y t^ {� City of Northampton `Status of`Permit±l A Building Department Cu a ye it &� : r: (° a� 2 Main Street Se r s $ ivaaria w " ' � a : �} Room 100 0 itig t,, C� Northampton, MA 01060 Two 4 ' uctu . ,Ia i ate &T � nN , phone 413- 587 -1240 Fax 413- 587 -1272 'PI© tans #mfr 4 -� Othe�s �Y * V , ,. - APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1- SITE INFORMATION 1.1 Property Address: This section to be completed by office Q Map Lot Unit ne � \-4A(/1.15)1'3 " Zo Overlay District Elul St. CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: �,l N (Print) ilir����ess�M �� � n Telephone t i 13 �� $ ,.90.7 5 t � naCurrent M ture c--71 y 3 2.2 Auth i' ed Age 04 ,a�, ►pia „\ 7 L � {u rjrr 1p,, , - Name (Print) Current Mailing Address: (�, 4 413 531-49 Signature Telephone SECTION 3 ESTIMATED CONSTRUCTION! COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 30 (a) Building Permit Fee 1 2. Electrical r' (b) Estimated Total Cost of 1 � )'.J Construction from (6) 3. Plumbing Q i V Building Permit Fee 4. Mechanical (HVAC) V 5. Fire Protection / V 6. Total = 1 + 2 + 3 + 4 + 5 5 Check Number , � o 0 This Section Fo Official U se O nly ” ' Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date 1 i File # BP- 2010 -0193 APPLICANT /CONTACT PERSON ROBERT ARDIZZONI ADDRESS /PHONE 7 LAKESHORE DR HOLLAND (413) 531 -4841 PROPERTY LOCATION 785 BRIDGE RD MAP 18C PARCEL 079 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out '}Q Fee Paid 0� o iv dam Typeof Construction: CONSTRUCT 19 X 30 MSTR BDRM/BATH ADDITION New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 051547 3 sets of Plans / Plot Plan THE " • LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN . 1 RMATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay Signature • Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. ::110 f �.• BP- 2010 -0193 GIS #: COMMONWEALTH OF MASSACHUSETTS r it; I8C - 6 2 r CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0193 Project # JS- 2010 - 000235 Est. Cost: $50000.00 Fee: $300.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT ARDIZZONI 051547 Lot Size(sq. ft.): 20995.92 Owner: MOCK WILLIAM D Zoning: URB(100)/ Applicant: ROBERT ARDIZZONI AT: 785 BRIDGE RD Applicant Address: Phone: Insurance: 7 LAKESHORE DR (413) 531 -4841 WC HOLLANDMA01521 ISSUED ON:8/21/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT 19 X 30 MSTR BDRM /BATH ADDITION POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 8/21/2009 0:00:00 $300.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo NUK I t1AMVlF nniA3m.,1 i PREPARED FOR „ , N oF � WILLIAM D. MOCK RAND L SCALE: 1 =20 AUGUST 17, 2009 iz� N HAROLD L. EATON AND ASSOCIATES, INC. 0 032 REGISTERED PROFESSIONAL LAND SURVEYORS ` t, �,� 235 RUSSELL STREET — HADLEY MASSACHUSETTS ' \� suRvO 413 584 -7599 413 - 585 -5976 (fax) / % email — hleaton®aol.com 0' 20' 40' 60' = Ns immoi milmomimii EN am r milmil y i - --'---- 3 N 81'47'13" W 140.02' la cc.)t•te0 \ roc-;5 1 i \ - i / \ 4, BOOK 8006, PAGE 198 A �yX _y PLAN BOOK 23, PAGES 32 & 33 LOTS #8 & # i ��p \ds:7 I � 1 F`- l w k n' - :j ZI a 5.7ft , I I`I - - - � f o O / < �� co N g. N \ \ � / 30.3 d � \ m ° k y / #785 \ , T 33. t � c O ' Et I MV �\ 6ft `./ 35.2ft / — "' 15.Oft 15.Oft ASSESSORS MAP 18C PARCEL 079 ZONING DISTRICT URB rn oci BUILDING SETBACK LINE S 81'44 E 139.92' BRIDGE ROAD ('J C,- "EXISTING CONDITIONS PLAN OF LAND IN — — ..Ll1 11 1 t i- r r ' 9, RA 'CRS IC, °/C. gotta Ride 9 . x G cg , 1 /o1c CD)( s \AEg-\k; 3 TA b 341 `Ca mV\ cf, %y - 1 scale 3500 les COmAG VIII F ',)1v6R 11A) t aANc, 3sices . J oil-two..4J I 1 n.L) V. 0 0 V. WV Vi. Q. a at 0 aivi. a L.) 211.1 V tl a il L • . < c,N). A ....................... 9 )i , 1 I 7vi , A ,/,/ ............ --, , 0) 0 1 0 k— o re. 4 ,H . 0 , ‘ - ' - ' e — - —-- -- ----- ---- -- I) ---* \-- )4' - - - 5 -- . • - - --)- - c "". , ' CZ 1 i ....-- 2 - A , gizZ=).• - ( z:2 . N ‘ , . HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two -year period shall not be considered a home owner." The building department for the City of Northampton wants person(s) who seek to use the home owner exemption, to act as their own construction supervisor, to be aware that by doing so you become responsible for compliance with state building codes and regulations The inspection praces &equires that the building department be called to inspect work at various stages, which include foundation /footings (before backfill). sonotube holes (before pour), a rough building inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired secure their proper _permits. in_conjunction _to- thebuilding_permitissued, nd_that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Address of work location '* i The Commonwealth of Massachusetts ,..— Department of Industrial Accidents �:i..= P Office of Investig,ations • . =v. - 1.=. loo - 600 Washington Street 7 =–'74-- = g Boston, MA 02111 „ " www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers Applicant Information Please Print LegibIv Name ( Business /Organization/Individ „ at): R 1/T AP.6 17:10 1 V '' Address: 7 L( e 1 �3 CC-. 0 2. I�'� l 1. \ 1 City /State/Zip: Phone.#: 913 531 - y gel ) Are you an employer? Check the appropriate box: Type of project (required): / 1-E] I am a employer with Q 4 ❑ I am a general contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub- contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. K Remodeling ship and have. no ioyees These sub - contractors have 8- f , Demol�uon working for me in an c aci employees and have workers' Y aP ty- $ - 9. la Building addition [No workers' comp. insurance _ comp.:nsurance. _ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I --am a-homeawnerdoin fork -- ce _kl_ave exercised he ❑ gltnnbiagrepairs or additions myself. No workers' comp. right of exemption per MGL 12. ❑ Roof repairs - insurance required.] t c. 152, § 1(4), and we have no . employees. [No workers' 13.0 Other comp. insurance required] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit . indicating they are doing all work and then hire outside contractors roust submit a new affidavit indicating sucl>_ :Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have employees- If the subcontractors have employees, they must provide their workers' comp - policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information Insurance Company Name: C t `i A ' R 1 p_C - Policy # or Self-ins. Lic. #: 6 5 6 C) V ` -9 - 1 I o t I U G-L 1 0O Expiration Date: Q (” la 1 0 Job Site Address: 4J ) t, Cit /S tate/Zip:* ad I.\(V +3k) 1A Attach a copy of the workers' compensation oficy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section - 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1500.00 and/or one -year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator: 'J a advised that a copy of this statement may be forwarded to the Office of Investisations of the DIA for insurance coverage verification the ai an penalties ofperjury that i ti id a the nforrnaonproved.abav' tztrue_aniLcarrecL ry I do hereby: ce d Aft. p 1111 d r+ c.- 7a - Signature: • Date: . Phone #: L/ 3 5 t - x-1.1 l Q I r Official use only: Do riot write in thKarea, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): -1: Board of Health 2. Building Department 3. City/Town 4. Electrical Inspector 5. Plumbing Inspector 6. Other :- Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Seervis R Not Applicable ❑ Name of License Holder : O ! J ► ( J\ 1 ?,� 1 J License Number L.1Kc S Nba3 Dv Wo\ f N (Y)p, O\5aA 515 y 7 Address 0 Expiration Date � )�' X 113 5 31 -£17 Signature Telephone Do O 9. Rectiste Home^lmpr'overnent:Contractor . .§ ... , * , ., . _ . . . Not Applicable ❑ K c-)bOnt 1 5 3g0 Company Name Registration Number 31-c4 1-10hR l /adi1 Address Expiration Date Telephone iii SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G:L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes No ❑ . The_currcent_exemption for "homeowners " Pxtended to include occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two - year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference'to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of o t ampton sr. finances; a e • ndTb atZ-• . - _ - s- CreneralLaws- Annotated. Homeowner Signature f , A ■ of J SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ] Replacement Windows Alteration(s) n Roofing 0 Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [E] Siding [p] Other [D] Brief Description of Proposed L T U n n 0 1 n �. C p � i 0 - T WO e Work: 1� Iv 1�►:r � � I l Alteration of existing bedroom Yes ` No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes &No Plans Attached Roll - Sheet 6a-'lf Neonhouse; andedi4 di#I to- exil"stinq i < houslnc , campiete the-following: a. Use of building : One Family V Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? y d. Proposed Square footage of new construction. 30`-' Dimensions I I tx a--5 e. Number of stories? j f. Method of heating? t\)(4 Fireplaces or Woodstoves 1JO Number of each g. Energy Conservation Compliance. MO Masscheck Energy Compliance form attached? Iv 0 h. Type of construction W ocx) ri A('nC d in i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floo plat Yes No j. Depth of basement or cellar floor below finished grade 0 k. Will building conform to the Building and Zoning regulations? J Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN , OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, fRaS rig Mr me , as Owner of the subject property ,/y l ' hereby authorize g0 beiLk 14 R2. r�1 to a- • - my behalf, in all matters relative to work authorized by this building permit application. 4/-1.21-11C_ o ALA 1 D■ 0 C A Si. ature of Owner Date il „IMF 1, r ■ as Owner /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. ) Signed u r th pains and penal 'es of p rjury. 0 c' ao no P\ Print Name APP i / i p p C.-- (AL)9_____t;____0 Signature of Owner /Agent Date 1 Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size T ---75D-4----- _..._M _. Q.. ._. 1 Frontage� ....__.__ __ _ . .._ ... ___ _ , .._.:.._.1J.�_. .._ _ _..._. Setbacks Front Side L.'_... R. L:? R: �/ C1 Rear _. ._ ---- -. Building Height -- - -- Bldg. Square Footage ' F '_. Open Space Footage „_ .__ �, % - -.. parking) (Lot area minus bldg & paved mm �...,. ...._.., # of Parking Spaces —___,j _ _ Fill: E i (volume & Location) . ' _ __ _ _., . .._. _. A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 400 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Pagel and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ,Date Issued C. Do any signs exist on the property? YES 0 NO 44) IF YES, describe size, type and location: 0 - "D: "Wee propose' c - nges to or a rtions of s> nterided`foi the property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, cavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton Std } Building Department Cu ,10i1)43seway 'emi 212 Main Street Room 100 Waa _ `2. Northampton, MA 01060 r \ phone 413 -587 -1240 Fax 413 -587 -1272 i . ' = s C � g APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 _ - SITE INFORMATION 1.1 Property Address: This section to be completed by office 5 Bv■c)c\e, _ 1 Map Lot Unit �l /�,� p (� Zone Overlay District ' v `�� r '" EImSt -District CB District SECTION 2 ; PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: AO S -__ %9s BEd) N (Print) Current Mailing 9 s: c U Telephone '� ■ nature .2 Authorized Agent:. • Obc� — t �rc) N 1 7 L (Akc S l -lake '� �Z Noilpo) (/')A Name (Print) Current Mailing Address: 015a.‘ r �� -H A-531- I Signature Telephone SECTION 3- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building a9 5Q0 (a) Building Permit Fee 2. Electrical ( b ) Estimated Total Cost of 5 0 © Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) // 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Q ©0 Check Number - This Section For Official Use Only Date Building Permit Number: Issued.._ Signature: Building Commissioner /Inspector of Buildings Date \V File # BP -2010 -0171 APPLICANT /CONTACT PERSON RO ADDRESS /PHONE 7 LAKESHORE DID 3 1 -4841 PROPERTY LOCATION 785 BRIDGE R MAP 18C PARCEL 079 001 ZONE URA THIS SEC PERMI USE ONLY EC ED D DATE DATE ZONING FORM FILLED OUT Fee Paid Buildint Permit Filled out • or Fee Paid P • • ri Tvpeof Construction: ADD 14 X 25 TO EXISTIN�.. New Construction Non Structural interior renovations Addition to Existin. Accesso Structure Buildin. Plans Included: ---'�� Owner/ Statement or License 051547 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN O. 13 0 - ED ON INFO ATION PRESENTED: I01°N Approved Additional permits required (see beloc PLANNING BOARD PERMIT REQUIRED UND1 Intermediate Project: Site Plan AND /OR er t With Site Vial'. Major Project: Site Plan AND /OR ` is Permit With Site P ZONING BOARD PERMIT REQUIRED UNDER: Finding Special Permit ce * an Received & Recorded at Registry of Deeds Proof . Other Permits Required: Curb Cut from DPW Water Availability Se wer Availa lth Septic Approval Board of Health Well Watability Board of Ilea ommitte Permit from Conservation Commission Perrot 1CB Architecture C Permit from Elm Street Commission Permit N Storm Water Management Demolition Delay Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zonin De P artment requirements and obtain all required permits from Board of Health, Conservation Commission, of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. 1 »> W,gr`: BP- 2010 -0171 GIS #: COMMONWEALTH OF MASSACHUSETTS % CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2010 -0171 Project # JS- 2010 - 000212 Est. Cost: $30000.00 Fee: $180.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT ARDIZZONI 051547 Lot Size(sq. ft.): 20995.92 Owner: MOCK WILLIAM D Zoning: URB(100)/ Applicant: ROBERT ARDIZZONI AT: 785 BRIDGE RD Applicant Address: Phone: Insurance: 7 LAKESHORE DR (413) 531 -4841 WC HOLLANDMA01521 ISSUED ON :8/27/2009 0 :00 :00 TO PERFORM THE FOLLOWING WORK :ADD 14 X 25 TO EXISTING GARAGE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 8/27/2009 0:00:00 $180.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo