Loading...
35-227 (7) City of Northampton *.' Massachusetts 4 *oT DEPARTMENT OF BUILDING INSPECTIONS �= I 212 Main Street • Municipal Building 5Jt =fib Northampton, MA 01060 sSl+fy°„ 113 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner w HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachu tts allows the homeowner the right under 780CMR 108.3.4 o act as his/her construction supervisor. a state defines "Homeowner” as, " Person(s) who owns parcel on which he/she resides or intend e, a one or two family dwelling, attached or deta ed structures accessory to such use and/o arm structures. A person who constructs more t n one home in a two- year period shall not be consid red a home owner." The building department for the C of Northampton wants any person( who seek to use the home owner exemption, to act as their o construction supervisor, to be a re that by doing so you become responsible for complian a with state building codes d regulations. The inspection process requires that the building dep rtment be called to inspec ork at various stages, which include foundation/footings before backfill sonotube holes befo our a rou h buildin ins ection before work is concealed insulatio ins ection if re u' ed and a final buildin ins ection. The building department requires these in pections before e work is concealed, failure to secure these ins ections can result in failure to obtain a cert' icate of occu anc until the work can be inspected. If the homeowner hires other trades to perfor work ectrical, plumbing & gas) the homeowner will be responsible to make sure that the trades hired cu their proper permits in conjunction to the building permit issued, and that they get their required spections. Failure of the individual trades to secure the permits and inspections as required can D the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signatur requesting exe ption) I will call to schedule all required buil ing inspections nece ary for the building permit issued to me. Date Address of work location 1 The Commonwealth of Massachusetts Department of Industrial Accidents f G64 Office of Investigations x 600 Washington Street Boston, MA 02111 ' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ii Please Print Legibly Name (Business/Organization/Individual): y C= c/C, c� �V-AtCb V\' Address: 32— City/State/Zip:V=l�V--2.V\C 'e. Phone #: J �cl 2-12) 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 1 6 ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.Z I am a sole proprietor or partner- listed on the attached sheet. 7.-A Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' g ❑ Building addition [No workers' comp. insurance comp. insurance. 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions required.] 3.F-1 I required.] a homeowner doing all work officers have exercised their 11.E] 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. tHo meowners 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: �--\� (Y s e�'" J /�-� Policy#or Self-ins. Lic.#: Gck.,) S�, ��PA '60 Z(Y434I Y Expiration Date: L:::� 0 Job Site Address: 58 QAD S(JPPex"�- � City/State/Zip: Attach a copy of the workers' co ensation 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 nd penalties of perjury that the information provided above is true and correct. S i ature: 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): 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 t 8.1 Licensed Construction Supervisor: Not Applicable £ , f � Name of License Holder: �..J �- �� �-'1 !�� C,1 ©5 3 5 License Number Address �— Expiration Date a Telephone 9.Registered Home Improvement Contractor.;. „_ ;!. . Not Applicable £ Company Name Registration Number Address Expiration Date / t.Vif'(M-L WA Telephone _ ocb 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 J n r.Egemption The curren emption for"homeowners"was extended to include Owner-occupied D llin s of one(1) or two(2)families and to allow suc omeowner to engage an individual for hire who does not posse license,provided that the owner acts as supervisor.CM 80 Sixth Edition Section 108.3.5.1. Definition of Homeowne erson(s)who own a parcel of land on which /she resides or intends to reside,on which there is,or is intended to be,a one o o family dwelling,attached or detac d structures accessory to such use and/or farm structures.A person who constructs a than one home in a -year period shall not be considered a homeowner. Such"homeowner"shall submit to the Buil Official,on a acceptable to the Building Official that he/she shall be responsible for all such work performed under t it ermit. As acting Construction Supervisor your presence on J 'te will be required from time to time,during and upon completion of the work for which this permit is iss Also be advised that with reference to Chapter (Workers'Compensate and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Dea of the Massachusetts General Law otated,you may be liable for person(s) you hire to perform work for you under s permit. The undersigned"homeowner"ce es and assumes responsibility for compliance with the Building Code,City of Northampton Ordinances,State id Local Zoning Laws and State of Massachusetts General Laws ated. Homeowner Signatur SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors 1- Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks Siding[❑j Other[❑j Brief Description of Proposed `, A^l A1\d Work: I(Yli��iTS.� L� � -�W S-� L/ V\,f� �'J Y'n�f Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. if New house and or addition to existlng h`ousinq, 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 I, 3-As—p 6 5o ll�J as Owner of the subject property hereby authorize to act on my half, in all matters relative to ork authorized by this building permit application. Signature of Owner If Date I, V 5?. � as Owner/Authorized Agent hereby declare that the tatements 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 Na e Signature of Owner/Agent Date Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zonin \ This column to bp ed' by. Building De ent Lot Size F 1 .. Frontage Setbacks Front } Side L: R:- LA R:= Rear Building Height Bldg.Square Footage Open Space FootageV T % (Lot area minus bldg&paved azkin ) ;L #of Parking Spaces Fill: ,:....d _.. ,..._. ,�..._..._ (volume&Loca' n) I` A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW Q YES Q ._..._»____� "X IF YES, date issued:1`" IF YES: Was the per it recorded at the Registry of Deeds? NO C) DONT KNOW 0 50 IF YES: enter Book ' P e and/or Document# — s B. Does the site contain a brook, bo of water wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to obtained from the Conservation Commission? Needs to be obtained 0 Obtain Q , Date Issued: C. Do any signs exist on the pr erty? YES Q NO 0 IF YES, describe siz type and location: 1 D. Are there any pr osed change or additions of signs in ed r the property? YES O NO Q IF YES, descrl e, 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 Q NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. _ Departmentuse onlx s i.r of Northampton Sfatus,ofPermtt fi 3 a a Fr fr Ia, ' Ij har@1 u ing Department Curb Cut/Dnve�ntay Perlrttt �} ` in t1, ntt{ i ,�i it r� Pxrr a r, ,x a r 5f f1' _ Z 2015 I 2 Main Street SP,Wef/SP.ptIClYal�ab411ty x Room 100 V1(9terlUUe1[Avatlabtllty ' _M_�rtha pton, MA 01060 f Tvvp S2ts'o Structural..Plans EIE�tr,�. l '' � 1 -'�� 1240 Fax 413-587-1272 06;; tat�erSpeoify� �', t1 � .._..:". .._°.. APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE.INFORMATION This section to be com leted by office 1.1 Property Address: p �,'�"`� L,�� j�,,,l�'F �� l�►n °� ..Map Lot Urnt r LI,�r'��c��.� � _Zone Overlay Disfrtct �i Efm wds t District CB DIstnct SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT . 2.1 Owner of Record: LL t � Name t) Current Mailing Address: Telephone Signature it 1 2.2 Authorized t: Name(Print) Current Mailing Address: rJ3© S air-M\ Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS. . Item Estimated Cost(Dollars)to be Official Use Only completed by ermit app licant 1. Building C71n'a J a7 (a)Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6 3. Plumbing o c7 �� Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) o c�7fl C7 �n Check Number Za This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissionerllnspectot of Buildings Date File#BP-2015-0920 APPLICANT/CONTACT PERSON JEFFREY BOTT ADDRESS/PHONE 32 Pine Street FLORENCE01062(413)530-6920 Q PROPERTY LOCATION 58 LADYSLIPPER LN MAP 35 PARCEL 227 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: RETILE MSTR BATH REPLACE VANITY&PLB-G FIX New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• - Owner/Statement or License 053157 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: 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 kdingfficial S n 3eu 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. 58 LADYSLIPPER LN BP-2015-0920 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 35 -227 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A1 Category:renovation BUILDING PERMIT Permit# BP-2015-0920 Project# JS-2015-001782 Est.Cost: $10000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JEFFREY BOTT 053157 Lot Size(sq.ft.): 32452.20 Owner: ZASHIN LYNN S&AMY P JACOBSON Zoning: Applicant: JEFFREY BOTT AT: 58 LADYSLIPPER LN Applicant Address: Phone: Insurance: 32 Pine Street (413) 530-6920 () Workers Compensation FLORENCEMA01062 ISSUED ON:41312015 0:00:00 TO PERFORM THE FOLLOWING WORK:RETILE MSTR BATH,REPLACE VANITY & PLBG FIX 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 4/3/2015 0:00:00 $60.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner