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'.•_1 MA ,7 t c.(2.). . . °' • r s3' + I i • iii • f f f f • B• m B' • • • B t p \ • ° 4o s 4:41 d f, B ti • a .... ; ..: p P • r •• r • ' '1 • • 4' • •'. • e p o • .s 1 • p {/• . . . - . alio x • s o yw a• 11-" • f jo • B; •' ii i • • • , : Pt • • til ■ B •• • s • r •• : , e • • ® • •a a B +•cB• as B¢ P ° • a ..• ..y L-,.- I ® B �� 1 r . .s.. n 1 Y 9� • :4, B ' - - - - - . , Ile -------)Pr ,, - f # E .,- ar ( 9R 010. :0 • V .•, Zb 9 -' a o ice' ® j -‘,1 ' (rill' r ' .. r O • - B 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 proceasiequires that the bu ildi n g 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- the-huilding 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 / 5--= ,2 G , I, - ae 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. AV Address of work location (iR D, ER tGLD QRW 1Le E FK.E W A n10Ga The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations • 600 Washington Street - .7=-Efif= • —Tar= ,q Boston, 1V1,1 0,2111 www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le2iblv Name (Business/Organization/Individual): Address: - City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type f project (required): • 1. 0 I am a employer with 4. 0 I am a general contractor and I 6. st New construction have hired the sub-contractors employees (full and/or part-time).* listed on the attached sheet 7. 0 Remodeling 2. I am a sole proprietor or partner- These sub-contractors have ship ;nil have no e..loyees 8. 0 Demol ' loyees and have workers working for me in any capacity. employees 9. 0 Building addition _ comp. insurance.t [No workers' comp. insurance irequire.d.] • El We are a corporation and its 10.0 Electrical repairs or additions 3. Yj ani .officer lave exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right Of exemption per MGL 12.Q Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.E.2rOther la: Oc._TAGON comp. insurance required./ G A7-6110 *Any applicant that checks box #1 must also fill out the section below showing their workers con pensatice 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. Jam an employer that is providing workers' compensation insurance for my employee& 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 51,500.00 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. Tie advised that a copy of this statement may be forwarded to the Office of Investieations of the DIA for insurance coveraee verification. I do hereby certify u der the pains andperzlties ofperjury that the information provided above_ittrue_and_correct______ . mglow; &mature : a c-% - Phone #: S8A0- - Official use only. D Write in this a, tabe by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): -L--Boa of Health 2. Building Department 3. City/Town Clerk 4. Electrical I ector 5. Plumbin Ins • ector 6. Other Contact Person: Phone #: • SECTION 8 - CONSTRUCTION SERVICES I ' 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9:4RegiSterec 10nie itip tsiteniiitit irit ° 4aiii ?: i x Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) J 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_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 1083.5.1. 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 amp on •ritnance , a e' u. • :r A �°' •-•4: * . . Laws- Annotated. Homeowner Signature _ ��''� SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ID Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [El Siding [Dl Other [Rf Brief Description of Proposed Work: _IP )(la. OCTAGON SCREENED GAZE; SC) Alteration of existing bedroom Yes No Adding new bedroom Yes ✓ No Attached Narrative Renovating unfinished basement Yes 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 Ta - 'OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT , 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 , 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 under the pains and penalties of perjury. Print Name 4 - Signature of Owner /Age �I/✓ it 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 Lot Size I i 00.O0 ,(14S, Siii L _ ___ Frontage 1 `} 5•4. I _ __J _________ Setbacks Front ..1.4140 i i 3 Side L: ".....V... R: L � 1 I.,: .. .. i R:1 ____.. Rear 77 _. Building Height * , .' Bldg. Square Footage t" i 17 3% Rao ! 1 LT.... Open Space Footage % (Lot area minus bldg & paved , t +1 q 115___1 ; F f---- parking) r t. _ # of Parking Spaces Fill: (volume & Location) L 11 1 - - i A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO • 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 r IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW ® YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 ,Date Issued: C. Do any signs exist on the property? YES ® NO 0 IF YES, describe size, type and Location: s PED X i N& LEFT PROh/T coizwe iZ - D: — Are - there ` any proposed changes o or a • • Lions o signs in a do ed for the property ? YES Q NO 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • ,City of Northampton nQM Building Department 212 Main Street Room 100 -� Northampton, MA 01060 � K - 2 4Vone 413 -587 -1240 Fax 413 -587 -1272 , 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 IIa I]I:EaFIE.Lt rsZiVE Map Lot Unit FLOTIZENC -E, /AA. Zone Overlay District EimSt District CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: .9RJ Name (Print) Current Mailing Address: 4i Sfi4v- 1�ka.. w ,.. Telep Signatu4 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone ._ ... ...................._ ..- ....._.._. SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building R ©0 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing i Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) A,000,°(? Check Number ,199N This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -0856 APPLICANT /CONTACT PERSON CATLETT KATHRIN M ADDRESS /PHONE P 0 BOX 60407 FLORENCE (413) 586 -1442 0 PROPERTY LOCATION 118 DEERFIELD DR MAP 29 PARCEL 185 001 ZONE URA(100) / /WSP/WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 02 D_ hag re) Typeof Construction: ERECT 12 X 12 GAZEBO 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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF t ATION PRESENTED: i 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 41 'F) l i() Sign e of Building fficial 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. 118 DEERFIELD DR BP- 2010 -0856 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 185 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 -0856 Project # JS- 2010- 001275 Est. Cost: $2000.00 Fee: $28.80 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group Homeowner as Contractor Lot Size(sq. ft.): 14984.64 Owner: CATLETT KATHRIN M Zoning: URA(100) //WSP/WSP II Applicant: CATLETT KATHRIN M AT: 118 DEERFIELD DR Applicant Address: Phone: Insurance: P 0 BOX 60407 (413) 586 -1442 () FLORENCEMA01062 ISSUED ON:4/16/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: ERECT 12 X 12 GAZEBO Re :rn 'q fleet 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: !P1- C Rough: Rough: House # Foundation: t !0 :,11 Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: cYk / — f f CAAN`.. THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND RE • rr ' : ► .0:. Certificate of Occupanc gnature: FeeType: Date Paid: Amount: Building 4/16/2010 0:00:00 $28.80 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo