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Northampton, MA 01060 'F'fr i 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 /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 insp -- •s are made Ar I, _ .Lm�`�1 understand the above. (I maawher /resi • ent's sign. " re requesting exemption) I will call to sc eduie ail required building inspections necessary for the building permit issued to me. Date / a_c / .. Address of work location 6 a i k.--1; 0) k ,s,(-- III A-4 / 1 1 C) ( V U 2, :1"' The Commonwealth of Massachusetts Department of Industrial Accidents _ f _ 1 M� Office of Investigations ism" ...11,,f— . .� 600 Washington Street A �., Boston, MA 02111 • ;` 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. E I am a general contractor and I 6. n New construction employees (full and /or part- time).* have hired the sub - contractors 2. El I am a sole proprietor or partner listed on the attached sheet. 7. n Remodeling ship and have no employees These sub - contractors have 8. n Demolition working for me in any capacity. employees and have workers' 9. n Building addition o workers' comp. insurance comp. insurance. equired.] 5. n We are a corporation and its 10.0 Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. n Plumbing repairs 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.E Other i 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. ........._........ Signature: Date: Phone #: 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): I. oar v Health 2. Building Department 3. City/Town Clerk 4. Electrical I s Inspector 5. Pl Inpector ;3 d ^f 1 2 d' g t ,...... � p b - -- r 6. Other . Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed. Construction Supervisor: (- Ye) Not Appplicable Name of License Holder : l (\I ' 5 ( J g L(9 d License Number 33 6- y - R /?f( /(3 Address Expiration Date C - 0 1 14 v\_ ( �� --� Signa Ire �.. elephone AP. ( 36 C7S 1 9 ate isteed Ji • rtte;lm. rov mntContrac #or ,� __ y .m_ a r�«, _,�� _ <<�_ Not Applicable ❑ .. Li—. ►� 6 � 1 / yse) Company Na e Regis ation umber ��-f R ams' Address 1 Expiration Date ^� • __ 6 - . p Z (( b� c 7P 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 [ t Q `D c 11. home. Owner: Exemption 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 • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition Replacement endows Alteration(s) Roofing n Or Doors [ Accessory Bldg. i I Demolition ❑ New Signs [El] Decks [Ed Siding [151] Other [0] Brief D- . '. o Pro(. -d / �p� 1 Work: 1 - /L, l .. / 411 J �lw �"'� ' • 3 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa IfNevv -house and,orpaddition to ezistinq °tiousing;Xcomplefe.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? 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 CONTRACTORAPPLIES 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 Signature of Owner /Agent Date I Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information b , Existing Proposed Required by oning • This column to be filled in by - Building Department Lot Size Frontage Setbacks Front i Side L: R: Lill _ R: Rear e CC_ - eAc S Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: _` (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T 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 IF YES: enter Book ` Page; I and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 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: ': i D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO Q 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 (3 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. . aA4k`:4") UC A _ Deparfrnetrtt useton[y w , City of Northampton Status ofPerm # 4 ,,,,',,,,..44‘i 00 1041 s ' l �' ,* '3°" �a 1., tt °!: f� Building Department Curb,CutIDrtyeway,Perm � "I{ , F . 1 Jai 5 2012 t 4 y1, l - s£, 21 2 Main Street Sewer S ep t ic A v atl a btt 1 - • , -' �c' � � . ° ,_ t ( Room 100 Water/Wel1 AAailabil ' g � "4` �� t {,- ... ,,lt key + , 5§ ; � " >T.:' g G �fi � ,� 1 :n - ax u e .�rau te ic,: N orthampton, MA 01060 Two S etsofStr u cturalPlan NORTHAMF`c. MA0108 '-- s ��� hone 413 587 -1240 Fax 413 587 1272 5lte tar, 11 t v ',. w � 1 prv.� ti' x 4 Sa Y Other _,5,,,,,;., 4i''',. 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: //�� �� Ma �� Lot '� Untt ® ���� / Zon Overlay District �/ ( / b Elrri°St. District CB D istrict SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: /� r-- Name (Print Current Mailing A9idress: 1 n 1:3" : - Telephone e l 3 sv�.�, s� � Sig ature e 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3.-.ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be z , Official Use.Only . , completed by permit applicant , "'g 1. Building 1 .3 / 0 b� (a)' Building' Permit Fee 2. Electrical (b) Estimated Total 'Cost of ` ( / 0 e-)0 Construction from (6) ,. 0 _ , 3. Plumbing ® ` Building Permit Fee 4. Mechanical (HVAC) � , , _ 5. Fire Protection g . r 6. Total = (1 +2 +3 +4 +5) 4 /1- ©6� C heck Number - ., ,. 6(-5 This Section For Official- Use Only ' Date Building Permit Number: ' Issued: Signature: Building Commissioner /Inspector of Buildings Date • File # BP- 2012 -1166 y� APPLICANT /CONTACT PERSON STEPHEN YOSHEN , J ADDRESS/PHONE P 0 BOX 41 CUMMINGTON (413) 695 -7801 0 PROPERTY LOCATION 62 MIDDLE ST MAP 23A PARCEL 057 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid 1 .50") Building Permit Filled out Fee Paid Typeof Construction: Addition New Construction Non Structural interior renovations Addition to Existing Accesso Structure Building Plans Included: Owner/ Statement or License 88490 3 sets of Plans / Plot Plan THE FOLLOWING A N HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION P SENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ 35 ' 34j �J 7 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 V 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 Demolitio'- lay Allarag, .410":41&allt sr(--.21?"-/ Si: re o Building •ffr al 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. July 12, 2012 Daniel Trenner 62 Middle Street Florence MA 01062 Northampton Building Department & Northampton Planning Department, To Whom it may concern, On June 25th I submitted a proposal for renovations on my home at 62 Middle St, in Florence... File # BP- 2012 -1166 It was reviewed on June 28 and returned to me needing an additional finding under 350.9.3(A)7 I have reviewed the Plot Plan that I received as part of the closing on my house in 2008. A copy is attached. After review i am providing a more detailed description of the east setbacks on my house, which are larger than I originally thought, as the plot boundary is NOT parallel to the building itself, but in fact widens to the northeast corner. More accurate measurements are now provided... adjusted on the original drawings i provided, and on the Plot plan, now enclosed. Thank you for your attention to this matter. Sincerely, darit. \\ r ; c 7 : Daniel Tre ner File # BP- 2012 -1166 APPLICANT /CONTACT PERSON STEPHEN YOSHEN 0 P9-' LJ *- M ADDRESS/PHONE P 0 BOX 41 CUMMINGTON (413) 695 -7801 0 PROPERTY LOCATION 62 MIDDLE ST MAP 23A PARCEL 057 001 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 `� Typeof Construction: CONSTRUCT 3RD FLR ADDITION WBALCONY, ENCLOSE SIDE PORCH & REPLACEMENT WINDOWS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 88490 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFQRMATION 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 Demolp elay A MP , ' Si: . re of Buil tint Of icial 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. 62 MIDDLE ST BP- 2012 -1166 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 057 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- 2012 -1166 Project # JS- 2012- 001989 Est. Cost: $14000.00 Fee: $84.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STEPHEN YOSHEN 88490 Lot Size(sq. ft.): 6795.36 Owner: TRENNER EDGAR & NOREEN & DANIEL TRENNER Zoning: URB(100)/ Applicant: STEPHEN YOSHEN AT: 62 MIDDLE ST Applicant Address: Phone: Insurance: P 0 BOX 41 (413) 695 -7801 0 CUMMINGTONMA01026 ISSUED ON:7/26/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT 3RD FLR ADDITION W /BALCONY, ENCLOSE SIDE PORCH & REPLACEMENT WINDOWS 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 7/26/2012 0:00:00 $84.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner