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29-504 • 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 rou h building inspection (before work is concealed), insulation inspection (ifreouired) 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 1, 1( --5s' `u g � � -�r� 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 _ P j . 1: _ 4 The Commonwealth of Massachusetts _,, _ Department of Industrial Accidents • l _ tiff t l - Office of Investigations ' _._a =, a 600 Washington Street . :11 =ritfr mgmer 4,7 . Boston, MA 02111 • � � a www mass gov /dia . • -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LegibIv Name ( Business /Organization/Indivirinal): . - - Address: • - City /State/Zip: - Phone. #: Are you an employer? Check the appropriate box: Type of project (required): / 1. ❑ I am a employer with 4. 0 I am a general contractor and I 6. 0 New construction employees (full and/or part-time).* have 4 red the sub- contractors 2.. Q I am a sole proprietor or partner- listed on the attached sheet 7. 0 RemodeJin¢ ship and have no enployees These sub - contractors have. . 8. ❑ Demolition Comp working for me in an ew loyees and workers' .. - 9. lung Y c j WorkeTS-' : �1 addition �_}required..] _}required..] j insurance 5. 0 We are a corporation and its 10. Electrical repairs or addictions 3_ I am a homeowner doing all work officers havexercised their 11.0 Plumbing repairs or additions • myself [No workers' comp. ri rt of exemption per MGL 12.0 Roof repairs • insurance required.] t • c. 152, §1(4), and we have no employees. No workers' 134 Other • comp- incr�a ee I•gUU.Cd,j. • *My applicant-that checks box #1- must. also fill out the section below showing their workers' - compensation policy information. t Homeowners _who submit this affidavit.indic sting they are doing all work and tbea. hire outside contractors must submit anew affidavit indicating 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.lithe 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: C' /Stn - - • • 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 ofMGL c: 152 can lead to the imposition of Priinin4 penalties of a fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties iu the form of a STOP WORK-ORDER and a fne of up to $250.00 a day against the violator Be advised that a copy of this statement maybe forwarded to the Office of Inve Qations - of the DIA for` - insurance coverage verification I hereby certify u _:. the pains. � pe aatties of perjray that the information provrdei ab av " -747 Signature :1;-;IS . Date: 5/2 C I 0 - . Phone #: .. _. Official use only Do not write in this area, to be completed by city or town officwl City or Town: cease # _ _ _ . 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 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone °P �f� Not Applicable ❑ 9. Fteiit�terer#.I{t�le - � eme `;•°wr'�br� � ,, y �� �,., .� ��;. � ' PP 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 ❑ *ap:: Via. 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 Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature X (a a SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors El Accessory Bldg. ❑ Demolition El New Signs [0] Decks [U1 Siding [M] Other [CO /OX/ Brief Description of Proposed , J / Work: ii : ?-ii I L' Qof d- d ,.S 0,! • (I G�OOv� /J"CQa Alteration of existing bedroom Yes No Adding new bedroom Yes No be-reP /a 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 7a - 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 r, ��I V Signature of Owner/Agent Date 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 L 1 1 1 Frontage 1 'i 1i Setbacks Front ; Side L:E 1 R:1 _ L:1 € R:1 1 Rear E Building Height l 1 ? l Bldg. Square Footage I J L = 1 I 1 1 % Open Space Footage % i (Lot area minus bldg &paved __` E - parking) # of Parking Spaces Fill: 1 I (volume & Location) - 3 1 A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Cr DONT KNOW 0 YES 0 IF YES, date issued:1 I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book } Pa and /or Document #i B. Does the site contain a brook, body of water or wetlands? NO ef DONT KNOW Q YES Q 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 ei IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: i z E. Will the construction activity disturb (clearing, grading, ex vation, 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 Buittik Department p ti 0 212 ain Street s p � / � k` oom 100 No ampton, MA 01060 phone 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 ilitt-i'tne4bi ve Map Lot Unit' /o'ence, -0/ 6 2 Zone = Overlay District Etat St. District Ca 0 :Stn.& SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: j).' i i )a ivtina /o ve r loren�.� f77f1- n/a (, 7 Name (Print) Current Mailing Address: , _ �/ 4i -- cc- 71 F) X C �i CC t I�r�a'�" -- f Telephone - 5 Signatur �( 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 (a) Building Permit Fee Apk -i/Jp ei/a/e 40e/V( / 51) 2. ElectricT (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number 9 This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -1057 APPLICANT /CONTACT PERSON DOLMA TASHI & THUPTEN CHOEDEN ADDRESS/PHONE 10 MATTHEW DR FLORENCE (413) 585 -8180 () PROPERTY LOCATION 10 MATTHEW DR MAP 29 PARCEL 504 001 ZONE URA(100) //WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out � ) 1 fre ts fp �� s Fee Paid Typeof Construction: REPLACE 10 X 10 DECK W /SAME 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFAMATION 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 L � 4 S 1 2 -7 // D 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. BP- 2010 -1057 GIS #: COMMONWEALTH OF MASSACHUSETTS :Block 29 - 504 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 -1057 Project # JS- 2010- 001558 Est. Cost: $500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 6011.28 Owner: DOLMA TASHI & THUPTEN CHOEDEN Zoning: URA(100) //WSP Applicant: DOLMA TASHI & THUPTEN CHOEDEN AT: 10 MATTHEW DR Applicant Address: Phone: Insurance: 10 MATTHEW DR (413) 585 -8180 0 FLORENCEMA01062 ISSUED ON:5/27/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE 10 X 10 DECK W /SAME 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 5/27/2010 0:00:00 $50.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo s-d P A-c 1 .... Irl r .t. t--------Oci i cm I r -4 /.. Ir-' 1 ---1 I 0 L4 1 „QA 6 ,aakj " _ l411)119 : tix . =27 IA j • .. ' . I. c--oaqA z• • Cuiff -, dpjam sks 1 .t) I,, ••"/ • ,..• , 1 r r ''' ' ''' -' ..* ''''''''' ' ‘ .... -, -.• 7 g Oo ' „. , , tv i t Tr% ....■ ......■„•-■.,..........„•....,,,.. , , , ..........,................... f i 1 s : 10 f' ,o 1 0017 0 71.,2001 010Z l .. ,r) s' VI v Z nr viViVvrall , u", • 1... '"..... 3 ‘ ..... 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Lei fe A - ve / / l e 2 / / 265i - t , s Lippe / ail r/ /.‘t 56.51 A a r 1 F a 5 / /is / 4 a Y-7/ f3a-Ct (1 11(11O0 1)y sup ze) ,s60 LK L_St a v e 2) " Pir -Twat-is 6 AcHiu5,\,R wos-‘6kzi•,-s y\uf, CO( ( e &)‘ Ai mu/ d ?Oa ti bI xt faPild st ft C 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 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 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 `/ I Gz, L 1 u nderstand the above. (Home owner /resident's ignature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. 1 /Date /Address of work V location 1 O i" \a e (1oaq. t -- )c 1ltvA —coo The Commonwealth of Massachusetts Department of Industrial Accidents _ Office of Investigations °Ii 600 Washington Street i =war= Boston, MA 02111 y ; . , 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 er with 4 0 I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub- contractors listed on the attached sheet. 7. ❑ Remodeling 2. ❑ I am a sole proprietor or partner- ship and have no employees These sub - contractors have. 8. ❑ Deaol on working for me in any capacity. employees and have workers' Y P ty" # 9" 0 Budding addition [No workers' comp. insurance comp..msurance. required.] 5. We are a corporation and its 10 "0 Electrical repairs or additions officers have4xercised their 3. I am a homeowner doing a work 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 theirworicers' 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" lithe 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 MM., 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 fne 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 Investisations of the DIA for insurance coverage verification I do_ : eby certify under a pains and pen s cif perjury that the information provided islrue_arutcorrect. _ __ C :... tare: e- S kA �I I II ate- 0, -- Ppone #: , ! 7 Official use only Do not write in this area, to be completed by city or town ojfciaL City or Town: Permit/License # Issuing Authority (circle one) 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6.Other ti \ i f Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9. Registered Home Improvement Contractor Not Applicable ❑ 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 ❑ 11 — Home Owner, Exemjition 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 i ome a mpton Ordinances, State and cal Zoning Law nd State of Massachusetts General Laws Annotated. owne r Signature l 14 it - A SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition El Replacement Windows Alteration(s), ❑ Roofing ❑ Or Doors D «� Accessory Bldg. ❑ Demolition El New Signs [D] Decks IScl Siding [D] Other [D) /©y /I) Brief Description of Proposed Work: 1 's ‘- + 0*- `eG Alteration of existing bedroom Yes 11.--" Adding new bedroom Yes L.-- No Attached Narrative Renovating unfinished basement Yes t/ Plans Attached Roll - Sheet sa. If New house and 'or'addition:ta existing housing, conmlete the following: 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? " _ A 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 f 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 /\// I , 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, , 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 ,...... Do/,_, Signature of Owner /Agent Date ‘; /'1 f t— / vv 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 Nu C N11- 14 C '.�c Lot Size 44 „ ....� C Frontage .£ -._ ._..__.. _.... , •,....., Setbacks Front Side Rear _. /Vv (H'►-jNCnb= Building Height 3 n f crlkueoe... N © � Bldg. Square Footage 74' % Open Space Footage (Lot area minus bldg & paved 34_{lr parking) Ns .raAV/, # of Parking Spaces - _ -• -• v Fill: (volume & Location) / 1/ A. Has a S eclat 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 Q DONT KNOW Q YES Q IF YES: enter Book Page and /or Document # 1f B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? ._. ....... ............................... .. Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES ® N O V �,� IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, 1 avation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. , Depa rtment use only City of Northampton Status of Permit: Building Department curbout/Dr P tt 212 Main Street : , „ eptic A vai #ability Room 100 kr/UUell Aval tabi!►ty Northampton, MA 01060 Twt� Sets of Sf1.1**1 n phone 413- 587 -1240 Fax 413- 587 -1272 Pi�ite Ptans Oth Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING 1 SECTION - SITE INFORMATION P This section to be completed by office 1.1 Property Address: b i 1 l Map Lot Unit f` t�J V (:_e_ � Zone Ov erlay District L Z Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: V 7�i � ' rGi '- (c.-� t l�5 )' bp /o fr1 f-!,1 i�s���� fro f it ' of Name (P nt) Current Mailing Addre s � „ ,3` L' Telephone Signature 2.2 Authorized Agent: u Name (Print) kurrent Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cos (Dollars) to be Official Use Only Tel completed by permit applicant v 1. Building # ;oe (a)`Building' Permit Fee 2. Electrical (b) E stimat ed Total Cost of C from (6) 3. Plumbing Building P ermit Fee 4. Mechanical (HVAC) 5. Fire Protection 1,...,0 6. Total = (1 + 2 + 3 + 4 + 5) ' ©C) C heck Number This Section For Offici Use Only Date Building Permit Number: Issued Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -1057 APPLICANT /CONTACT PERSON DOLMA TASHI & THUPTEN CHOEDEN ADDRESS /PHONE 10 MATTHEW DR FLORENCE (413) 585 -8180 Q PROPERTY LOCATION 10 MATTHEW DR MAP 29 PARCEL 504 001 ZONE URA(100) / /WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out WI' � Fee Paid ! l Typeof Construction: REPLACE 10 X 10 W/ 18 X7 ECK 6 17 0 New Construction d Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License a a 3 sets of Plans / Plot Plan pEC OM2 I ^ 1 �.$�[[ le SPACE THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON tot INFQ MATION PRESENTED: Approved Additional permits required (see below) 1 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 1c4-(iNj) (1140 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. aluaTHEW DR BP- 2010 -1057 GIS #: COMMONWEALTH OF MASSACHUSETTS t 29 - 514 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 -1057 Project # JS- 2010- 001558 Est. Cost: $500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 6011.28 Owner: DOLMA TASHI & THUPTEN CHOEDEN Zoning: URA(100) //WSP Applicant: DOLMA TASHI & THUPTEN CHOEDEN AT: 10 MATTHEW DR Applicant Address: Phone: Insurance: 10 MATTHEW DR (413) 585 -8180 0 FLORENCEMA01062 ISSUED ON:6/16/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REPLACE 10 X 10 W/ 18 X12 DECK 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 5/27/2010 0:00:00 $50.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo