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35-199 (5) f I � r { • i I � { I i t� I _ I \ I • - I �W. a I f I I I S � I � S k -jZ,, Jj = 4� ti e. rsj It j Oy (riff Pf �nrfl�a�lt}Itol� _— �.. 6 �t asanrllntrll e' _ DEPARTMENT OP DUILDD\IC INSPECTiol.'S j 212 Main Strcct ' Municipal Building ?Northampton, Mass. 01060 WORTC;It'S CONIPEIiiSATTON CatSURANCE AFFMt rj—z' (Ii ccnscc'Jpermi ttcc) - %Vith a principal place of busines redden at: — sr (phoney=) SY ��20 (su-�t/ci tr/staicla p) do hereby certify, under thc.pz.ins --nd pe1121ties of perJury, hzt ( ) I am an employer providing the followinL'%vorkci's coinocnsZt;on covemge for my emplovees worlong on tills job: - --' 5. (Iasurn=Comr ml) (Polic:Numbccr) (T.:oiravor, D2j—) i O I am a sole proprietor, geacral contractor or homeowner (ClIcie one) and 112ve hired the contractors listed below w);o have the following worker's comoeri_sadon policies: Oi Co-'.lnc] or) (IRR 7311(: COtT]D1S])'/l�OUCi ?��uII1ir:) �i:);-wjon Datc) (N2MC of CoOtrezor) (In.su7aa-.. ComDan-wPolim, \uncrf) Date) (Name of Connaao;) Omsurancz- Company/PoUq- N:imb,-r) (Expimao0 Daic) (Namc of Coonactor) (I=ran Comcany/Policy Numb r) (Expimtioa Darr). (atrsdr �oc.�!dcd,ifac�z�•to c)ctud=infor'm,1on pc-tniaizz to.17 coax---=o:-J) I { ) I am'a sore proprietor and Gave no ooe worldDg for me. II am.a home owner perforrni.ng all the work myself. I NOTE:plese be ecrzrt tfi,•v f Je bcc=o =n.bo emPlay pcsom w cU -• -• c=s—zcjoo a rrnt woric on.d..ciL^E of aoc mcrr th n tfx t�itr is uix�the homoo voc r=do a oa the Vv z4rzppanca�=thcro :r not C==11y oc=d.-cal to be eitploye�uac'.e the w4,-�s�__ as Act(GUI 52,=l(5)1 appli=6cm by a homcom-o=fer a liner_.or pcnait rs_y cmrd=—the I-PI n of a.a-=:Ploy-<uoder dw W.+S -a C. .p...t a Ac,_ [godc o-". d tha a ooPy of Lb;-ctLL==u away b.for---id to tb.papunmcoa of Ind.+xriti Ac d a&Off o.of Iraur•oon for the oovcrbc vcireaioa and UL-a L-ilmt to tocurr)eoverzac under=cxioa 23A of htdL 152 eta lad to the=pcm6oa of mraiw]peackies ooali-r-mg of a fine orup to 51300.00 andfor impriyoome=orup to ooe y=r rzd civil praattio ifl 6,form of a Stop WorE Ord=and, ft=0(:S 1 00.00-d_y tiling me I i For d,,-,...— u.c ody PcTmjt NuIDbcs Z7 QS� 1./'3p°-- Lot K SirnatumofLi 4crmiucc e i � � �l'ilsssxchusrtts r DEPARTMENT OF BUILDDQTG INSPECTIONS INSPECTOR '212 Main Street • Municipal Building Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as },is/her construction sup��:-,"isor. The state defines"Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or hvo fa dry 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 understand the above. (Home owner/resi ent's signature r esting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Address of work location S147` f OZ7" r i 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 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 maybe 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 ;romeowner ton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Signature SECTION r DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [tom] Decks [Ell" Siding[0] Other[I1 Brief Description of Propos y C Work: Y X T ,2J171� .tl Alteration of epsting bedroom Yes /No Adding new bedroom Yes 1/ No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.ff 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. 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 1 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 2 ids Signature of Owner/ ent 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 �/ /`-� `/ ,5q Frontage Setbacks Front Side L: /� R: 7 Rear Q 31 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 DONT KNOW 0 YES Q IF YES, date issued: \� IF YES: Was the permit recorded at the Registry of Deeds? NO () DONT KNOW Q YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO IV DON'T KNOW © YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained 0 , Date Issued: C. Do any signs exist on the property? YES O 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 IV 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 O NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability. Northampton, MA 01060 Two Sots of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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 /Y7 (,�Ijf4-rs P,T RIN Map Lot Unit Af d 6106 Z Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: r7LEi42V //ZZ/-/ sax -s f T Zb Name rint 7 Current Mai Ad ess: o 15'Y + Telephone Signature 2.2 Authorized Agent: Name(Print durrent Mailing Address: Signature Telephone 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 Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection 6. Total=0 +2+3+4+5) Check Number �'r This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date VW 1�-s� File#BP-2006-0151 APPLICANT/CONTACT PERSON O'LEARY STEVEN J&NINA M ADDRESS/PHONE 1144 BURTS PIT RD FLORENCE 9fa-o PROPERTY LOCATION 1144 BURTS PIT RD d MAP 35 PARCEL 199 001 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Permit Filled out Fee Paid 17 Typeof Construction: EXPAND DECK 12 X 16 I 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 INF 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 Commiss' &/ za-6777 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. 1144 BURTS PIT RD BP-2006-0151 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 - 199 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2006-0151 Project# JS-2006-0231 Est. Cost: $4100.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin Homeowner as Contractor Lot Size(sq. ft.): 11543.40 Owner: O'LEARY STEVEN J&NINA M Zoning: SR Applicant. O'LEARY STEVEN J & NINA M AT: 1144 BURTS PIT RD Applicant Address: Phone: Insurance: 1144 BURTS PIT RD O 586-9820 O FLORENCEMA01062 ISSUED ON:8117105 0:00:00 TO PERFORM THE FOLLOWING WORK.-EXPAND DECK 12 X 16 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 8/17/05 0:00:00 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 1144 BURTS PIT RD BP-2006-0151 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-Block:35- 199 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2006-0151 Project# JS-2006-0231 Est.Cost: $4100.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin: Homeowner as Contractor Lot Size(sq.ft.): 11543.40 Owner: OTEARY STEVEN J&NINA M Zoning: SR Applicant: O'LEARY STEVEN J & NINA M AT. 1144 BURTS PIT RD Applicant Address: Phone: Insurance: 1144 BURTS PIT RD O 586-9820 O FLORENCEMA01062 ISSUED ON:8117105 0:00:00 TO PERFORM THE FOLLOWING WORK.-EXPAND DECK 12 X 16 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 Sisnature• FeeType• Date Paid: Amount: Building 8/17/05 0:00:00 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo