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29-403 (3) T 3ut ti�tQ' Iid UOSUOJIC. paoeid iapio qof so pred uaaq •suoiltpuoo qof Ig of luamisnfpe i 800Z/9I/ZI =Poltuad seq aa3 aigeolidde ssaltm paidoo.to paseaiai sal' UNH�ar pule alts gofuo aogeoguan of laafgns 800Z/9I/zl =PouilisaQ oq lou Ismu Pule uBisap Teucouo ue si sfgl (a�VVo1E�z a.xe uan1S saoil>�FSap azcs suoisuaunp IId i „8£L- � `L S £6 0£48/V1 MEMO ..... 4ZZLS£M2! SS4l 00 SUAK Tem 0£xZLI�M1�� ;l0 M - f ,6£ ' ..8L ,.4Z .a V 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, 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 oflndustrialAccidents -- Office bf Investigations =` 600 Washington Street Boston, MA 02111 ~> www.fnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �pj gx; Address: ?a. 'Fat d9 City/State/Zip: IlYa 01011-- Phone #: 1//3 Are you an employer?Check the appropriate box: Type of project(required): 1.VI am a employer with_1 4. ❑ I am a general contractor and I 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. ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ 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.F-1 Electrical repairs or additions ❑Plumbing repairs or additions i d their i h officers have exercised I L 3.❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.7 Roof repairs . insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.71 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: AVA"o Policy#or Self-ins.Lic. #: pV C 2 - 315`--36 Z — 0/-7 Expiration Date: a� ivt>v %o Job Site Address: S441.1,46 gY1 City/State/Zip: o60k Attach a copy of the workers' compensation policy declaration age(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. 1 do hereby certify under lae pains and penaltie f r' ry that the information provided above is true and correct. Sienature: Date: 4AI e' Phone#: •- 5 Official use only. Do not write in this area,to be completed by city or town ofciaL Citv 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 b.Other Contact Person: Phone#: q SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction—Supervisor: Not Applicable ❑ Name of License Holder: L/.S 17 License Number Addre s Expiration Date Signature Telephone 9.Registered Home Improvement"Contractor: Not Applicable ❑ 7 lit Company Name gistration Number Address c� Expiration Date �d 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 Ekema ion' 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 14 r � SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors 177 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding[lam] Other[0) Brief Descri tion of Proposed Work: I din Al w ` " Alteration of existing bedroom Yes No Adding new bedroom Yes IV/No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. If New house and or addition to existing housing, complete 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. floodplaih 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 1,jl> 6-y d / )/ Ed El a x ce as Owner of the subject property hereby uth rize to a n m behalf, in all matters relative to work authorized by this building permit a lication. Sig a u 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 nder the pains and penal'es of perjury. c Print r '7 Sig ture f Owner/Agent Da 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 Frontage _. .. .. Setbacks Front Side L: R:, ._ L: R .., Rear Building Height Bldg.Square Footage % Open Space Footage ° (Lot area minus bldg&paved my " arkin #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 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 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 0 Obtained 0 , Date Issued C. Do any signs exist on the property? YES NO 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: 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. Department use only City of Northampton Status I of Permit: Building Department Curb uUDriveway Permit' 212 Main Street Semrer/SeptidAvaiiability ; Room 100 WaterlUUe11 Availability ` Northampton, MA 01060 Two sets of Stru .1?4 - phone 413-587-1240 Fax 413-587-1272 PloUStte Other Specie APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR T.#p F,AMILT,-Q ELLING SECTION 1 -SITE INFORMATION ';) 1.1 Property Address: This section to be tompleted by office - —` �+ ; /J 2d Map tot Unit 0/ 0 6 Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Vnnos-,-aa. -aosan 6 QV 12 Nai ruure int) Current Mailing Address: —. Teleph���- Sign 2.2 A uthorized A ent:0 A/ /1',,Pl In Name fPn n Current Mai ing Address: Si ure Telephone - .0 SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building © (a) Building Permit Fee 2. Electrical �„� (b) Estimated Total Cost of 6tc) Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) , 1-49 Check Number b2s This Section For Official Use Only Building Permit Number: IIsssued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2009-0631 APPLICANT/CONTACT PERSON TOM DOLAN ADDRESS/PHONE 172 SOUTH STREET CHESTERFIELD (413) 585-0612 PROPERTY LOCATION 54 SANDY HILL RD MAP 29 PARCEL 403 001 ZONE URAO00,//WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid uil 'n Permit Filled out L Paid Typeof Construction: Repair water damage;kitchen and bathroom 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 INFO ATION 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 01 /0? 0 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. 54 SANDY HILL RD BP-2009-0631 GIS#* COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-403 CITY OF NORTHAMPTON Lot:-001 PERSONS CON`1'RACTING WITH UNREGISTERED CONTRACTORS Permit: Buildi g DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c,142A), Category: B y ILDI G PERMIT. Permit# BP-2009-0631 Project# JS-2009-000915 Est.Cost: $23400.00 Fee: $140.40 PERMISSION IS HEREBY GRANTED TO: Const, Class: Contractor: License: Use Group: TOM DOLAN Lot Size(sq. ft.): 33628.32 Owner: BRONSON VANESSA&STEPHEN A BROZO Zoning: r�?RA(100 /.�/WSP Applicant: TOM DOLAN Applicant Address: _-_ Phone: Insuratice: P O BOX 29 t (413) 585-0612 CHESTERFIELDMA01012 ISSUED 0N:1/7/2009 0:00:00 TO PERFORM THE FOLLOWING WORK.-Repair water damage; kitchen and bathroom 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:l���n� House# Foundation: Driveway Final: Final: J' - / � Final- /4, Rough Frame: Gas: Fire Department Fireplace/Chimney; Rougli: Oil: Insulation: Final: Smoke: Finat: OK 3� THIS PERMIT MAY BE REVOKED BY THE C' TY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. ' Certificate of OCCUpancy Signature: FeeTyRe: Date"Paid Amount: Building 1/7/2009 0:00:00 $140.406289 212 Main Street,Phone(4 13-3)587-1240, Fax: (4 5 87-12 72 Building Commissioner-Anthony Patillo