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35-108 (3)R� tw•r nr zo �\Todljalllptoil ►3aitrhnrrita' w\� DEPARTMEIJT OP ©UrLDrNG INSPECTIONS 212 ?Hain Street ' Municipal Building Northampton, Mass. 01060 WOR10E Z'S CO)/[PENSA` ION CNSUTZAhCF AI IMAVIT 01 c=SCC/pC11111 t tcc ) %with a pf- b-Icipal place of business residence at: (phone ') (sTr�t/ci ty /statcrz�p) do hereby certify, under the pp-ns and penalties of pegury, .hat ( ) I am an employer providing the following %vorker's colnnensZZJon coverage for Illy eluplovccs wortaing on this job (Innu-� Cocsr -y) (Potic: Nu- �nix'r) ;piraaon Dzlc) ( ) I am a sole propretor, general contractor or �eox7ne� (cu i. e one) and have hired the coouactors listed below who have the foilo4m9, s comoens2don policies: (iltlroc of Co ^.r ^cior) (In1 1M11 COIi1D11 } "/1 GU�i T�Un1 -•=T) rk_>:_)t;J::•Q� iillC) (N41ne of CODIT3CIOr) (Name of Coaa- actor) Ras -aranc ComDaa rPot cti \tinc�r) (Insuranc:. Compan)•/PoUq- Numb,-j) (—E1-pimuon Date) (Exairaon Date) (Name, of Contractor) (L su=e -- Comrany/Pohcy Numbs) tT-xpi-.1don Da1c) . (nrli.c±l ;iocsl ihlct to ar u& inrorm,noo pctaiain.s to .11 ooCi'r._G'1i:3) ( am a sole proprietor and have no one working for me. ( ) I am,a home owner performing all the work; myself. NOTE: pl=c be ewue th.• -im:Je boa).a-Av =n j, employ p,,, W d3 ,;•.,� c rc,'av work oo . d.•cUli^Z of oo( m0- the ! . t--'?j in the bomoa-,o r rc ide or ea tb.e — we to be caiployc3 11 the ..a-i:cf: comp a=-aim An (GL152 =1(5)� application by e bomco -ocr far c bccr- = or Pcrmrt ray �•rdl the Icga] ctanu of en cn toyer under dw W«kolc Compooaalioa Act I undrnUnd tb.d a copy of tbaa. rrai mood m.y be Coc —dn d to tha Dcportmcat of Ind.ixricl &mdco- offioe oC L-- for the covcrasc vaZcalioo &M U1tat L•.iltac to xairc b3vcrnsc undcr soctiofl 25A of MOL 151 can Iad to tba ija;->itioa of cruniaA Pc -lliat o0oaiIiag of • faoe of up to S 1.500.00 .nNor of up to ooc year Lod aril pmatuo in d c form or. Stop Work Order and e fim of 5100.00 i day tpi= ay-- C r For d-pL.nn+UM -r oily — n t [�CTIIrJ l 11fDtX'1 Lot Si�natum otLicroscclpermiuc�. , . -_ -- 4- THAMP7. O O Gl ity of Nart4aimptan �ASSRCt�I[StttS DEPARTMENT OF BUILDDNG INSPECTIONS INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as !Js/her construction sup,.:-,- sor. 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 (�&A, 6J d 4 AkJ i 1A, �-� understand the above. (Home owner /resident's signatur+questing exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date `� I Y /D �- Address of work I location I-)- I -" , d a/►1 � i 1,1Ar,I 4e, of Owner/ SECTION 8 - CONSTRUCTION SERVICES Date 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9 Re; iii - red9.14 e4iiuravemeritCon ctor•° „ T 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...... ❑ ...................... ............................... ...................... ............................... 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 N ampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature C LA6s d,l C. vv, ► �"^ U SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Alteration(s) ❑ Roofing ❑ Windows Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [) Siding [ ] Other[ ] Brief Description of Proposed (� 1, I �0 Work: t t t J 1�1,c_ CVV-N LA_) l yt C ak.c J 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. Mascheck 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 ! (a l L�^ V l!.l�i �Q.I.+n as Owner of the subject I, � property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner w +^ Date as Owner /Authorized Agent hereby declare that the statements and informat' n on the foregoing application are true and accurate, to the best of my knowledge and belief. Sig d under the pains and penalties of perjury. CA Print Name C-11 / � r� C 1 ti er tnn G% 6 Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION A. Has a Special Permit/Variance /Finding ever been issued for /on the site? NO DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES 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 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ?YES — No IF YES, describe size, type and location: Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side Rear L: R: L: R: 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 DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES 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 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ?YES — No IF YES, describe size, type and location: Ci f Northampton ;J5887 g Department L� t� U V Main Street 1 +-' oom 100 l 12 - X004 N pton, MA 01060 I phone 41240 Fax 413 - 587 -1272 I APPLlI" ,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be comoleted;by office 06 C cwt )j aAS l x LAA Q Maip'l - - lot Unit F l t1i,Q,t ti RA4., " D lot, i 1 -79 q0 Overlay District Elm'St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) (, ai dre iA �� G f 0 6 Curren Mlin — C..- `` Signature Telephope I —4- 1 ;L0 4— 2.2 Authorized Agent: GC-- 1 j e. 1.t.. L tr Po &X x` I -3 C-- Name (Print G � ' �-- �,,., 7w. Current Mailing Address: [ ( eXJ � 010 z 7 �- Signature Telephone 1-411) 26 ?? SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building 6 )L (a) Building Permit Fee 2. Electrical (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 G '" This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date 3 26 CAHILLANE TERR GIS #: -.Ajqjgk 35 -108 Lot: -001 Permit: Building Category Permit # BP- 2005 -0127 Project # JS- 2005 -0132 Est. Cost: $2000.00 Fee: $25.00 Const. Class: Use Group: Lot Size(sa. ft.): 9931.68 Zoning: SR BP- 2005 -0127 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142AA) BUILDING PERMIT PERMISSION IS HEREBY GRANTED TO: Contractor: License: Homeowner as Contractor Owner: TEMPLETON GERALDINE Applicant: TEMPLETON GERALDINE AT. 26 CAHILLANE TERR Applicant Address: Phone: Insurance: 26 CAHILLANE TERR FLORENCEMA01062 ISSUED ON :812104 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 5 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• Receipt No: Date Paid: Check No: Amount: Building 8/2/04 0:00:00 8748 $25.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo 26 CAHILLANE TERR GIS #: Map:Block: 35 - 108 Lot: -001 Permit: Building Category: Permit # BP- 2005 -0127 Project # JS- 2005 -0132 Est. Cost: $2000.00 Fee: $25.00 Const. Class: Use Group: Lot Sizelsq,_ft-.1- 9931.68 Zonin @: SR BP- 2005 -0127 COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT PERMISSION IS HEREBY GRANTED TO: Contractor: License: Homeowner as Contractor Owner: TENIPLETON GERALDINE Applicant: 'i tk�i- L`c iiiv vE v:Lviiv AT. 26 CAHILLANE TERR Applicant Address: Phone: Insurance: P 0 BOX 123 FLORENCEMA01062 -0123 ISSUED ON :812104 0 :00 :00 TO PERFORM THE FOLLOWING WORK.INSTALL 5 REPLACEMENT WINDOWS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Underground: Service: Meter: Footings: Rough: Rough: House # Driveway Final: Final: Final: Gas: Fire Department Rough: Oil: Final: Smoke: Building Inspector Foundation: Rough Frame: Fireplace /Chimney: Insulation: Final: Q k< !�J :10 - 6 y —4V THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPT�O.�N- UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. �� e rcrhifirn a of (lrri roan Signature: i /✓/ FeeTv e:v Receipt No: Date Paid: Check No: Amount: Building 8/2/04 0:00:00 8748 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo $25.00