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31A-124 (2) City of Northampton ,:'`' yf� Massachusetts 5 i DEPARTMENT OF BUILDING INSPECTIONS faa' 212 Main Street • Municipal Building 1" Northampton, MA 01060 r`f'Nyi fit' 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 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 of Massachusetts * -_. _. Department of Industrial Accidents -11 Office of Investigations ' �—" = 600 Washington Street g. • .. Boston,MA 02111 - , it www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): -e_ J iti'2 4 TI Address: 32_ ?Cam-- ' S City/State/Zip: (- c_c), G LI LL t 't A Phone #: S 0 6 5 o-17 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 4� 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.1K1 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. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ 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.❑ 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: t--� Policy#or Self-ins. Lic. #:(eL S°' co Ot)1 2013 4 Expiration Date: h/2f Za('f Job Site Address: I q 'mil/.-)�'— `J( City/State/Zip: (UO�//� 1yl'? h� i// 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 a V1 d penalties of perjury that the information provided above is true and correct Signature: O---D Date: 1i 7,-) J 13 C..\\--&---". Phone#: 530 C'9 b 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 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: -3 . ISte License Number 't tvle:. Sr GSts-- 58151 Address Expiration Date .� 530 69,Z-0 Signature Telephone 1 e' `ie ed ome m•roriemer „Confrac o . • . r"t "'n-j1 tali, r ' ' Not Applicable ❑ 3 E-f V ,,1 C TteAC l V.S Co H/c- (0/ 1 Company Name �J 4.2- Registration Number Z Ft 5r Address Expiration Date Telephone b?2-C) ZS'-) SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M C 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 ❑ '©ineOwn .r Exemption The current exemption for"homeowners"was extended to include Owner-occupies % • ellings of one(1) or two(2)families and to allow such homeowner to engage an individual for hire who does not po .-ss a license,provided that the owner acts as supervisor.CMR 780, Sixth Edition Section 108.3.5.1. De :• on of Homeowner:Person(s)who own a parcel of land on w ch he/she resides or intends to reside;on which there is,or is in - •-d to be,a one or two family dwelling,attached or ached structures accessory to such use and/or farm structures.A perso i • o constructs more than one home in • two-year period shall not be considered a homeowner. Such"homeowner"shall . 't to the Building Official,o. . form acceptable to the Building Official,that he/she shall be responsible for all such work pe : med under the b ding permit. As acting Construction Supervisor you . -sence o• he job site will be required from time to time,during and upon completion of the work for which this permit is 1 •-d. Also be advised that with reference to Chapte 52(Wo - 'Compensation) and Chapter 153(Liability of Employers to Employees for injuries not resulting in D- .)of the Massachus- _ eneral Laws Annotated,you may be liable for person(s) you hire to perform work for you and‘- his permit. The undersigned"homeowner" ifies and assumes responsibility for compli.. ith the State Building Code,City of Northampton Ordinances, e and Local Zoning Laws and State of Massachusetts Ge -' Laws Annotated. Homeowner Si• ature 1 • J 'SECTION 5-DESCRIPTION OF'PROPOSED WORK(check all applicable) , b. New House ❑ Addition 'A Replacement Windows Alteration(s) TA Roofing Fl Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [0 Siding[D] Other[D] Brief Description of Proposed 0•4�t k((c-C\e� AI t to 03 ,3() 6Y-5-Work: \ / J Alteration of existing bedroom Yes-74" No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Gay -,i- e ii se f ad a i ddition to'ezistii g4haluiti ..corrtpr ete.' lief oliMing: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathroo c. Is there a garage attached? d. Proposed •.: - ootage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each ' g. Energy Conservation Compliance. check Energy Compliance form attached? h. Type of construction i. Is construction within 101 . of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement •r 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 ,TOBECOMPLE,TgD`WHEN ,:OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT x I, SCIS VS" a■r I'VY\ LA ? ,--- ,as Owner of the subject property � hereby authorize l V-€-----N <`3 ` to act n my b half, in all matters relative to wait authorized by this building permit application. 9 Si nature of er 1 Date 1 d21 (- ,as Owner/Authorized 9 A ent hereby ecl e ethat a staTDOt t nts 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 pe jury. e r-iz, a Print Name .-i. 'I1& l (— Signature of Owner/A• li \` Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Informat' a Existing Proposed Required by'Zoning • This column to be filled in by Building Department Lot Size s I i Frontage '' Setbacks Front .--, Side L: 2 ! R:11p, ! L:'N 1 R: �! Rear 141ii INCA 1 I Building Height i!! Bldg.Square Footage Q F-----1 % r-----1 = i I Open Space Footage ! (Lot area minus bldg&paved i E parking) #of Parking Spaces Fill: ! _ _ _;� .____ ....�___...._. _ I , (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW 0 YES 0 IF YES, date issued:1 1 IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book I Page' and/or Document#1 B. Does the site contain a brook, body of water or wetlands? NO" 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 0 , Date Issued: 1 C. Do any signs exist on the property? YES 0 NO t i4 I 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 V IF YES, describe size, type and location: 1 Y 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 ® NO ID IF YES,then a Northampton Storm Water Management Permit from the DPW is required. `i` a 4r 't e•41 y ttl:e a t rf City of Northampton S us i er. f ,� 9� . , :T. JUL Building Department is .- 4 - 212 Main Street Se =tl a1.4..."'4$!:'£ :I' m ' - DEPT OF BUILDING INSPECTI Room 100 e o . :• � " ; rnml iaMPTON.MA 01060 s a Northampton, MA 01060 s e phone 413-587-1240 Fax 413-587-1272 't. jniar lci rfet ZA.f oe a a#� g ,{ *fi gs t>:.�.�n�, :uw..a�a+aNC fin APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORMATION 1" This section to be completed by office 1.1 Property Address: ' `' u �� �=T`j` cT a. '. 's .0 Lor,:% ' �*,p A Unit , �' �"'.., ��- T � "' Y �� one.11' 7 , z i i.fi. OYerla Dis rict"a ' fi * �t m 'eq,p - :': rA;i' •'zti.ti:Z' " Z c trl, tj•N`* Xh. Elm St:Dwstr c Y '"' * 'Ig ..if +CB D trfct . k�. � i1.o 'SECTION 2 PROPERTY.OWNERSHIP/AUTHORIZED AGENT ,. m 2.1 Owner of Record: eI vrte5 -4' S c/..5Av0, (—�' 1-- I ,Ec,J T-r s Name(Print) Current Mailing Address: - iµt1 l 6)122.," jTelephone -,/ Signature i 441°3-) 2.2 Authorized Agent: Name(Print) Current Mailing Address: 1 4 ,11∎1: 5 3c.s 69.2 S.natu - Telephone SE 7 eN 3 ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant ., _ , 1. Building l' (a)Building Permit Fee f r 2. Electrical ` (b)Estlmated;Total Cost of t ( Construction from(6) 3. Plumbing 35(2rt) Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection : 6 Total=(1 +2+3+4+5) � 00C Chec)t Number t-e_s 5,. o This`Section For Official Use Only is Building'Permit Number: Date Issued. Signature Building Commissioner/Inspector of Buildings ,. Date • File#BP-2014-0102 APPLICANT/CONTACT PERSON JEFFREY BOTT ADDRESS/PHONE 32 Pine Street FLORENCE (413)530-6920 0 '.d.itui I-Q 6.1(." PROPERTY LOCATION 14 JEWETT ST 4)3 MAP 31A PARCEL 124 001 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 ag--2 �D Fee Paid JJa J Typeof Construction: REMODEL KITCHEN&ADD 5 X6 MUDROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 053157 �/ ��� gxec 3 sets of Plans/Plot Plan l c u`c THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORfIATION PRESENTED: t./A-pproved 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 dif emolition Delay 11 TY--/3 ignature of Building • ficial 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 JEWETT ST BP-2014-0102 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A- 124 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ADDITION BUILDING PERMIT Permit# BP-2014-0102 Project# JS-2014-000199 Est. Cost: $40000.00 Fee: $240.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JEFFREY BOTT 053157 Lot Size(sq. ft.): 10541.52 Owner: COPE JAMES&SUSAN Zoning:URB(100)/ Applicant: JEFFREY BOTT AT: 14 JEWETT ST Applicant Address: Phone: Insurance: 32 Pine Street (413) 530-6920 () Workers Compensation FLORENCEMA01062 ISSUED ON:8/7/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:REMODEL KITCHEN & ADD 5 X6 MUDROOM 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 8/7/2013 0:00:00 $240.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner