Loading...
22D-006 (2) Z O O Crxfy of NorthaillptaIt z r $ � �1i+lassacf�usetfs AI DEPARTMENT OF BUILDIJTG 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 78OCNM 108.3.4 to act as his/her construction supr:- 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 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 s g The Commonwealth of Massachusetts Department of Industrial Accidents Office of In vestigations ' d 600 Washington Street Boston,MA 02111 www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly L , Name(Business/Organization/Individual): �'E00 hQri lahtl�t) Address: S 1' TA�;Q Q d Ttyyy C e. City/State/Zip: Phone#: 'L-j 710 Are you an employer?Check the appropriate bog: Type of project(required): 4. I am a general contractor and I 1.❑ I am a employer with loyees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. a sole proprietor or partner- listed on the attached sheet. 7. New ship and have.no employees These sub-contractors have g, R Demolition working for me in any capacity. employees and have workers' insurance. 9. ❑ Building addition [No workers' comp.insurance comp. required.] 5. F-1 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 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 131-1 Other comp.insurance required.] "Any appiicayt 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. ZContractors 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: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip:' 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above iis��true and correct. Signature: �, �11 �� Date: CO 1'r%'� Phone#: Li (-3 ' SoZ '7rc.fp Official use only. Do not write in this area,to be completed by city or town offcciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: t SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder �1 1.7 a&ems , o k GS 6-7 `1+ License Number -� e w o Tf rya�c ►vlA- 0160 1 r� t o Address Expiration Date 1i 1,4,:�& Y1 . --SZq .�/yf0 Signature 6 Telephone 9 Reaste�eil`(lorsjjie iinpra�reineriCantractoE /� � f�`$-" �.. Not Applicable ❑ O f-� '�46MA+ T cl�i 4,nA i�S-,0641. 4 Company Name Registration Number 61 9,,444 'lna L"-a6 Dn 1± 0 1 v-z7 31 IS-Ion Address Expiration Date Telephone a f 'SZ a- 7140 SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT'(M.G.1—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 buildA permit. Signed Affidavit Attached Yes....... No...... ❑ vwemm 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 fob 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) E Roofing ❑ Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [E3] Decks [p Siding [E3] Other(0] Brief Description of Proposed Work: N1014- i�Q 5 Z1' � �"`M ,�- QA: ► t )tr-U :: d-OA- ;'5 W e- . Alteration of existing bedroom Yes i/ No Adding new bedroom Yes i/No Attached Narrative Renovating unfinished basement Yes _ i,-1 No Plans Attached Roll -Sheet sa.if New hocise and oradclitior�faexrstl�g ftoiiinctt cartp�efthe,fa[Cowlna: 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. 1. 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 as Owner of the subject property �t hereby authorize '' I&SI G V� to my beh all tters relative work authorized by this building permit application. , 2 ` b.-� Z � /0 7 Signature of Owner Date �gp2'b" `I v 1 1 as Owner/ thoriz hereby declare that a statements,and i ormation on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ;C I f Print Name / 7-a�� �e Signature of Ow er/Agent 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 Frontage Setbacks Front Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved i #of Parking Spaces (volume&Location) A. Has a Special Perm it/Voriance/Fndi ng ever been issued for/on the site? � � �� NO ����� DON'T VV KNO �^� YES ��� IF YES, date issued: IF YES: Was the permit recorded ut the Registry ofDeeds? NO K } DON7KNOVV YES�� IF YES: enter Book Page and/or Document#�___ | �� B. Does the site contain abrook, body ofm/uterorwetlands? NO ����� DON'T KNOW v�� YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs tmbmobtained x�� Obtained � �~~�� Date�~� � . 0 C. Do any signs exist on the prope�y? 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 v~~\ NO IF YES, describe size, type and location: E. Will the construction activity distur grading,excotition,or filling)over 1 acre ovis it part ofo common plan that will disturb over 1acre? YEG ���) NO �m�~� IF YES,then a Northampton Storm Water Management,Permit from the DPW is required. ' ePa use on �` City of Northampton Stattts of PermtE PI �* t r t Building Department GurCGrittDrtvewaPerm► � 212 Main Street Sewert 0001 Yatfabtt t Room 100aterlfk�lelkA�ata6dG ° n Northampton, MA 01060wa Sets of Structura 'lans phone 413-587=1240 Fax 413-587-1272 PIotSite Plans '' k Other SpectfY 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 Unit I v l Tone Overfayr DistrrGt .Elrft St District ` CB.Dfst�ct. _ SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEDAGENT, 2.1 Owner of Record: Name(Print) /I ✓c Current ailing Address: Telephone ignatur 2.2 Authorize Agent: Name(Print) Current 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=(1 +2+3+4,+5) Check Number (J/ This Section ForOfficial Use Only Building Permit Number. Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2007-0778 APPLICANT/CONTACT PERSON ELIZABETH HOOK ADDRESS/PHONE 51 RIDGEWOOD TERR EASTHAMPTON (413) 529-2189 PROPERTY LOCATION 81 RYAN RD MAP 22D PARCEL 006 001 ZONE URA/WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Tvneof Construction: MOVE WASHER/DRYER FROM BASEMENT TO KITCHEN New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 079641 3 sets of Plans/Plot Plan THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION PRESENTED: _IZApproved 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 Commi Lc'.L1 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. a qs 7 BP-2007-0778 GIs#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON o : - PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2007-0778 Project# JS-2007-001250 Est. Cost: $2050.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ELIZABETH HOOK 079641 Lot Size(sq. ft.): 35719.20 Owner: HAWLEY STEPHEN&J EVELENE HUGUENIN Zoning: URA/WSP Applicant: ELIZABETH HOOK AT. 81 RYAN RD Applicant Address: Phone: Insurance: 51 RIDGEWOOD TERR (413) 529-2189 EASTHAMPTONMA01027 ISSUED ON:219120070:00:00 TO PERFORM THE FOLLOWING WORK.-MOVE WASHERIDRYER FROM BASEMENT TO KITCHEN 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 2/9/2007 0:00:00 $50.001101 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo 81 RYAN RD BP-2007-0778 GIs#: COMMONWEALTH OF MASSACHUSETTS Ma :Block: 22D-006 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: _BUILDING PERMIT Permit# BP-2007-0778 Project# JS-2007-001250 Est. Cost: $2050.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ELIZABETH HOOK 079641 Lot Size(sq. ft.): 35719.20 Owner: HAWLEY STEPHEN&J EVELENE HUGUENIN Zoning: URA/WSP Applicant: ELIZABETH HOOK A 7':8 1 RYAN R D Applicant Address: Phone: Insurance: 51 RIDGEWOOD TERR (413) 529-2189 EASTHAMPTONMA01027 ISSUED ON:21912007 0:00:00 TO PERFORM THE FOLLOWING WORK:MOVE WASHER/DRYER FROM BASEMENT TO KITCHEN 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: v Driveway Final: Final: Final:.21-2- 'J Rough Frame: Gas: Fire Department Fireplace/Chimney: 011: Rough:,,,i-�-j ��-�1 � � Insulation: Final: Smoke: Final:© K --� THIS PERMIT MAY BE %�VOKED BY THE C TY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES ANGULATI NS. Certificate of Occoanc _ Signature: FeeType: Wate Pai : Amount: Building 2/9/2007 0:00:00 $50.001101 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Conmiissioner- Anthony Patillo