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City of Northampton Massachusetts •w � <r DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building vb cam' Northampton, MA 01060 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 any 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 process requires that the building department be called to inspect work at various stages, which include foundation /footingsjbefore 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 the building permit issued, 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 a r' h understand the above. (Home owner /re . ident's signature requestin f e ption) I will call to schedule II req fired building inspectio necessary for the building permit issued to me. Date (2_ Address of work loc tion 1 T - (0 6 6 2- • The Commonwealth of Massachusetts ._.: _. Department of Industrial Accidents : °" Office of Investigations $'�` 600 Washington Street ., . �- Boston, MA 02111 v www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors/Electricians /Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Address: City /State /Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part- time).* have hired the sub - contractors 6. ❑New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [11 Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance. ' required.] 5. n We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11.0 Plumbing 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 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 must submit a new affidavit indicating such. 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 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 information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /State /Zip: Attach a copy of the workers' compensation policy 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 $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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. ignature: Date: 7 2-. ,c Q rr Phone #: \ ( l d Official use only. Do not write in this area, 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 CONSTRUCTION SERVICES t . , l 8.1 Licensed Construction Supervisor: / l Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 92e�`ist re edi�Iorie:liri. t ' Not Applicable ❑ N A Company Name Registration Number Address Expiration Date Telephone 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 ❑ \ \(? - 1w 3o `e vvner. ei p ' o n The current exemption for "homeowners" was extended to include Owner- 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 Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature 4111L _ AM. .4 ,SECTION 5- DESCRIPTION OF.PROPOSED WORK (check all `applicable) . New House ❑ Addition ❑ Replacement Windows Alteration(s) ©r Roofing n Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [O] Other [O] Brief Description of Proposed _ Work: — _ -_ - - s _ a , °� 2 Alteration of existing bedroom Yes f No Adding new bedroom • Yes ' No Attached Narrative Renovating unfinished basement Yes s✓ No Plans Attached Roll - Sheet r `+„4"r*f '�.' �.`7 *art'- .wr,°atA ?re•h .s,.0 w °'�*,a^^^�m� >, sm.«c. sa �lf ew housenandior addition to existi,nq hourmq,'compl`ete the.foll`owinq: a. Use of building : One Family f Two Family Other b. Number of rooms in each family unit: g Number of Bathrooms / c. Is there a garage attached? Ni d. Proposed Square footage of new construction. 0 Dimensions S x e. Number of stories? 2 • f. Method of heating? w� Fireplaces or Woodstoves Number of each I 44 - Energy Conservation g. Ener Compliance. N �� Masscheck Energy Compliance form attached? P liance. h. Type of construction CA-C2—al-t Ol -1- _-_,_ ��J A7� 1. Is construction within 100 ft. of wetlands? Yes '�No. Is construction within 100 yr. floodplain Yes ✓No j. Depth of basement or cellar floor below finished grade N'/ k. Will building conform to the Building and Zoning regulations? vYes No . I. Septic Tank City Sewer Private well City water Supply ✓ SECTION 7a - OWNER AUTHORIZATION -TO BE COMPLETED WHEN . - OWNERS AGENT OR APPLIES FOR BUILDING PERMIT -- I, lj \ n , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, F .. - 001/2.,r 0 � , as Owner /Authorized Agent hereby decla1''� &--) that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ,, 6 L, Print Name :)-- ? - L f 1 L. , 2___ Signature of 0 ' er /Agent Date 4 r Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information --t e Existing Proposed Required by'Z'oning N a This column to be filled in by l ( \ Building Department Lot Size 1_1„ %1, ' 1 a't^ -e-a- 1 1 Frontage Setbacks Front ( i . Side L: R: L:: R Rear I ' Building Height I s i Bldg. Square Footage -- ` i % I f Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: � E _w_ : k .. (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T KNOW __ YES 0 IF YES, date issued:; f IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page' i and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW > J YES (3 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 I NO IF YES, describe size, type and location: 3 D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO igr IF YES, describe size, type and location: t E. Will 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 Xar IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ��o a} De:a►tmet+ t1$�''`O `��/ i�1* Ci of No rtham pto n s£a�t�s:bf Peal, M Q ?.. \2 Bui • ing Department C r t/[) e P t 0 2 Main Street S � s ait a bl� G �pN`S , k° a rk G�NS p60 ' oom 100 s I::: d � b"ilabii , ' . a ��'� � �� Northampton, MA 01060 413- 587 -1272 : ' -, «u V ' -� ' ` not phone 413- 587 -1240 Fax P Jt � �_ ins '0 O.her 5 eci . $ fl s A. APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SI rE INFORMATION 1.1 Property Address: T hi s section to be co mp l e t ed by office i)14_,/14 � 4t Lot Unf' n x , aP; r� n t'-kA O IU 2— Zone Overla Di f'�.Qlt -^ e SZ ! y ;Elm S D istract CB Di strac t °' i SECTION 2 - PROPERTY OWN ERSHIPIAUTHORIZED AGE NT 2.1 Owner of Record: R 42 .r - So r�;h �-1- p�r� S�` F d vim (.,« �� a /0 � Z Name (Print) � Current a ilingdress: s( (0 D / 2 Telephone Signature 2.2 Authorized Agent: /v Name (Print) Current Mailing Address: Signature Telephone TION 3 = ESTIMATED CONSTRUCT COSTS Item a Estim ated Cost (Dol to be SEC Offic U se. Onl , co mpleted by permit applicant 1. Building C‘\ S6 (a) `Bwmg Pe rrriitFee 2. Electrical (b) E sti ld mate d Total Cost of 1S6--?-) Cctio ( ) 3. Plumbing Q�� Building Peonstrurmrt n from 6 Fe 4. Mechanical (HVAC) `��` 5. Fire Protection ` 6. To tal = (1 + 2 + 3 + 4 + 5) 3 Q fl Check ial N O umber s' This section For.Offi Use nly .. Building Permit N Date - Issuetl:. �� � � � ,, sin ature r. 1uildin Commissionerflnspector of But '.' Da • File # BP- 2012 -0859 1 APPLICANT /CONTACT PERSON SORKIN ROGER D & EVA CAMACHO - SANCHEZ , ,rI' e ' " ADDRESS/PHONE 14 PARK ST FLORENCE (413) 584 -1005 0 ri...6.4....43a.4.4.....„ PROPERTY LOCATION 14 PARK ST MAP 23A PARCEL 016 001 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 Fee Fee Paid 6 / I tr(7Z/ Tvpeof Construction: CONVERT CLOSET TO 1/2 BATH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION 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 ....00 v. 1 . P -lay P Signature of 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. 14 PARK ST BP- 2012 -0859 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 016 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2012 -0859 Project # JS- 2012- 001513 Est. Cost: $3000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 64033.20 Owner: SORKIN ROGER D & EVA CAMACHO - SANCHEZ Zoning: URB(100)/ Applicant: SORKIN ROGER D & EVA CAMACHO - SANCHEZ AT: 14 PARK ST Applicant Address: Phone: Insurance: 14 PARK ST (413) 584 -1005 O FLORENCEMA01062 ISSUED ON:4/5/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:CONVERT CLOSET TO 1/2 BATH 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 4/5/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner