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24C-032 • LOZS •-`_Jl ,. -wil, t ZI..M9 /1I. t — - — --7 , il r -1 T :91' " 29010 VW '2ONAHO1d � Nbrl a1IdHAHS 9l w , ` N >42AV10 W GIAVO lt Sf9 SO .asi,a,)i - 1 ■s_taDt7 s;i liott:2n.tysu •11 tr ltuPR� 11tte .1u t fr,,1N �ntltlt'tfl IQ) pl.trtrfl ( , li fr i i'l ttt (l.agp - s.1,)sntl )PS.tr It - S eozin./insa-impeayith �/ /V 1� /fp d / J,�(, 2 -` �y.te V / t/ V 4h i iti,ch AC YP -�\ Office of Consumer Affairs and usiness Regulation ,- 10 Park Plaza - Suite 5170 -` Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 143023 Type: Individual Expiration: 6/9/2012 Tr# 298757 DAVID M. CLARK DAVID CLARK 16 SHEFIELD LANE FLORENCE, MA 01062 Update Address and return card. Mark reason for change. Address I Renewal Employment Lost Card DPS -CA1 0 50M- 04/04- G101216 ,: /.e G min(1%G/eeildi G/ /r*ri.Jae>/ute Off ye of Consumer Affairs & Bus Regulat // License or registration valid for individul use only , ;. HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to Registration: 113023 Type: Office of Consumer Affairs and Business Regulation ' 10 Park Plaza - Suite 51'70 Expiration: 6/9/2.012 Individual ZA ' Boston, MA 02116 DAVID M. CLARK DAVID CLARK ( � N. E 16 SHEFIELD LANE „S-� r. ,.--,..�._''. - - FLORENCE, MA 01062 Undersecretary Not vali TWithout signature e • 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 owir 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 /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 jermits 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 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. Date Address of work location • ' • . , .■ The Commonwealth opfassachusetts Department of Indus Accidents Office of Investigations . 600 Washington Street Boston, MA 02111 T.t. „.......... ,&-• 0 • 7 ' www.mass.gov/dia ,.... -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly --1 Name pusineseor D (-lc v l'. 'J. 4,0 iz .,. . • Address: it <7 c F F / "e_Z:, &j1" p iAri 4- ,. t.1., i b City/State/Zip: - Phone.#: g (1- L 93 9 i . • ..,„ Are you an employer? Check the appropriate box: . Type of project (required): / 1. D I am a employer with I D • 0 I am a general contractor and I 6. 0 New coristraCtion have hired the sub-contractors .._",employees (full and/or part-time).* 2. be I am a sole proprietor or partner- lis-atd on the attached sheet 7. 0 Remodeling These sub-contractors have. ship nd. have no .loyees 8. 0 Demblidon working for me in any capacity. employees and have workers . , 9: 0 Building addiflOn [Na workers ' comp. insurance- # • 100 Electrical repairs or additions required.] 0 We are a corporation and its 3. 0 I am a homeowner doing all work officers haVe4xercised their . . 11.0 Plumbing repairs or additions myself [No workers' CO mp. right of exemption per MGL 12.123 Roof repairs . - insurance required.] t • . 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance =Tilted]. . • *Any applicant that checks box #1 must also fill out the section below showing their workers' C011ipelisation policy information. '.. • t Homeowneri who submit this dr:Ida:wit incScating they are doing all work and then hire outside contraetors must submit anew affidavit indicting such :contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contraimrshaste employee, they must provide their workers' comp. policy number. lain an employer that is providing workers' compensation insurance for my einplOyees. Below is the policy and job site informadon. • • •k Insurance Company Name: / Policy # or Self-bis. Lic. #: Expiration Date: . . Job Site Address: : City/Stafraip:' Attach a copy of the workers' compensation policy declaration page the policy number and expiration date). Failure to secure coverage as required Under SeCtiiiir25A 152 can kid to the irbioaitiari Of aihninil penalties of a fine up to S1,500.00 and/or one-year imprisonment as well as Civil penalties in the form of a STOP WORICORDER and a foie 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 iiiikiiii Da for insurance 6ciiiiiiie ireiifiCiiii _ Ito h e r e b y , c a r d : fr tut , t h e p ,," . a n d r p e n t i l e l i r f p e r j u r y t h a t t h e infornurtionprovidedizbovormet • .... ) ',.. ,...... _ . .. . - j--", o -• .) ..... Sianature: -- Phone ik e l i --i , .5' / - C ' .‘: - . - Official use only. Do not write in this area, tO be completed by city Or townOfficiaL City or Town: Issuing Authority (circle one): .. Permit/License # ' ......._____ . . . :1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical ,Ixspector 5. Plumbing Inspector 6. Other Contact Person: ' Phone #: i. . ,,, SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder : /1 5 F F f FLT LA License Number Address Expiration Date PLogGvCir Yf3 .5 Signat Telephone ^ Z G ! rL 3 G _ k 2' d�." `� Yr-' 4`PA �" ', � s,�j s ',`a ?r•s � _ � �.. Not Applicable ❑ 14L' r 0 C — v r Company Name Registration Number Address / 6 cp r r LAS FL-e OI 1 L Expiration Date Telephone SJ'7 5i3Y7 - ,. - / z SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.I-. c. 152, § 25C(61) 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 buildi g permit. Signed Affidavit Attached Yes No ❑ 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 a- umes responsibility for comp i e with the State Building Code, City of Northampton Ordinances, State and . ca Zo 'ng Laws . a State of Massachusetts neral Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) po & New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing }. Or Doors D Accessory Bldg. ❑ Demolition El New Signs [M] Decks [D Siding [0] Other [0] Brief Description of Proposed V. > Pr I R ra oh i' VC c, c N - Roof Work: VARi ©US SMFtLL RE efatri.S To ExT' +ti t Alteration of existing bedroom Yes No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes .i No Plans Attached Roll - Sheet a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. 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 k. Will building conform to the Building and Zoning regulations? 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 te. I 7/190 l •"/ /l ` $ , as Owner of the subject property ` 4 ((i/i/k to act on my behalf ' • . - - - e to wo ' ed by this building permit application. Signature of Owner - , Date .7J W U/ p Z fl-fl I( ^-�r I , as Owner /Authorized Agent hereby declare that the statements and i • .... - ion on t - • - . - • ..lication are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. � _DA VI tJl t� 1- A- A IC 4 Print Name Signature of Owner /Agent Date a /' 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 A t 1 g Lot Size l Frontage ) i l i Setbacks Front Side L:!!`-��--¥ R:I L:1 ? R: x Rear E__.._,_.1 Building Height ; 1 t i s 3 L i Bldg. Square Footage 1 1 t %= Open Space Footage % (Lot area minus bldg & paved f I i J i I parking) ._ # of Parking Spaces i i Fill: ._ 1 (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:! IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 I IF YES: enter Book t Pa I 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 ® Obtained ® , Date Issued C. Do any signs exist on the property? YES 0 NO 0 .- IF YES, describe size, type and location: i D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0 IF YES, describe size, type and location: 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 Q NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. f • City of Northampton EIVED Building Department 212 Main Street s. 5 nli Room 100 4 F orthampton, MA 01060 � • I - 4 3- 587 -1240 Fax 413 - 587- 1272�� 8� • INSPEC * C/FBUMDINri Wrnaroao ' a� APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: -70 N 6 „r“- - / --/- !L( 'Map Lot Unit one Overlay District Elrrr St' District . ` CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: ( 21 f i i2 IEl ; 51 44-44 /4iudj4 Name Current Mailing Address: Telephone Signature 2.2 Authorized Agent: i�U i A Ct.A R i< Name (Print) Current Mailing Address: F t_ c ce c i"'I 4S5 c4 Z Signature P Telephone y/,J 3"# tV3 V7 SECTION 3 - !ESTIMATED CONSTRUCTION: COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building *;' 2,<00 , •► (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection ( t- f 6. Total = (1 + 2 + 3 + 4 + 5) Check Number j { 31/45-- This Section For Official Use Only Building Permit Number. IIsssued: Signature: Building Commissioner/Inspector of Buildings Date 70 NORTH ELM ST BP- 2012 -0148 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24C - 032 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofing BUILDING PERMIT Permit # BP- 2012 -0148 Project # JS- 2012- 000214 Est. Cost: $2500.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DAVID CLARK 000635 Lot Size(sq. ft.): 20386.08 Owner: MURPHY DAVID Zoning: URB(100)/ Applicant: DAVID CLARK AT: 70 NORTH ELM ST Applicant Address: Phone: Insurance: 16 SHEFFIELD LN (413) 586 -4347 FLORENCEMA01062 ISSUED ON:8/5/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE PORCH ROOF 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 8/5/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner