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11C-036 (3) r SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. Demolition ❑ New Signs [0] Decks [CJ Siding [0] Other [p] Brief Description of Proposed Work: /U e-LL) U Er X 36 F i G A fLM y ''t— Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ;V No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a° 1f.Nevii hoIse and or addrtlon ex tstlna'h'ous�ng. ©ml�tete >tie fotlowinca 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 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 'C>- l L- as Owner /Authorized Agent hereby declare that the statemen s and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and pe Ities of perjury. Print Name L- Signildre of Owner /Agent SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9,.Reaistedi ..Home: °lniiar ©�rnenE Contr�cfir .,. °.� ,.._.. .�......:.. � , -...., e, 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...... ❑ 1, nkg "R ®1MUK1^ �`. - The-current-exemption for.`omeowners ". was ext ended 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. CAM 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 buildine 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 referencerto 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" c9ptifies and assumes respo sibility for compliance with the State Building Code, City of ort ampton r inances; a L`�ca1 o ' aeltusetts- General- Laws-Annotated. Homeowner Signature s° i The Commonwealth of Massachusetts Department of Industrial Accidents Office of -Investigations ' 600 Washington Street Boston, MA 02111 ''� �• ' www.massgov/dia - Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print Leiibly Name (Business/Organization /Individual): Address: City /State /Zip: Phone. #: Are you an employer?. Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4.. E] I am a general contractor and I employees (full and/or part time). * have hired the sub- contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7_ ❑ Remodeling ship and have no. enq>1oyees These sub - contractors have .8. ❑ De molition working for me in any capacity employees and have workers' 9. Building addition o workers' comp. insurance - comp.-ins�ance.� ❑ equired -I 5. ❑ We are a corporation and its 10 -0 Electrical repairs or additions 3. I am ��iomeo�vaer dsing all work - - - - -- -p er ha xerc mod. ice_- _41.-❑-giumbing repairs or additions myself Nl o workers' comp. right of exemption per MGL 12. ❑ Roof repairs insuran 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 M out the section below showing their workers' compensation policy information. t Homeowners who subznit this affidavit.indicatiag they are doing aU work and them hire outside contractors must submit anew 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. lam an employer that isproviding workers' compensation insurance for my employees. Below is the policy and job site formation. 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 MGT, 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. 1�e advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby: certi "der the pains and penalties erjury that the info rmation.provided abo..ve_isl-rueznd correct: Si tune: 12 ate; Pho Official rise only. Do not write ntliis area, to be comp eied y city or town oficiaL _City or Town: Permit/License # Issuing Authority (circle one): I: -Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrica Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: A i 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 xe ulations The inspecti on � cis e quines that the building department be calle 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 --- - - - - -- per -r- nits- in- conj.unction.to_thebu ape mir sssued,_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. 4 6 M - e owner Ires' is signature requestin . mption) I 11 call to sche all required building inspections necessary for the building permit issued to me. -rT Address of work location 6 S NOD FT � J E 73 � a� #.ws C ,�aa sC PT t J � rib I i I ' 1 aa � o �K 6 � n � G OM Mph •0 1 •p t A Cp }j - hi ?:4 '4.1y ., •Y. ;itn �� 4" :� a� '.^g!7�ilrt'�a ^R + ?c•.+,,..yiW + &a t,:'• �... a,.•.•; , ��. -NOTE- ' THIS PLAT IS COMPILED FROM DEEDS, PLANS AND OTHER SOURCES AND IS NOT TO BE CONSTRUED AS AN ACCURATE SURVEY AND IS NOT TO BE RECORDED. �o�T10 N of �cT �Z V' ` N sH:.o tJ � J A s ,CC ♦ T 1 14 TO: FLORENCE SAVINGS BANK & LAWYERS TITLE INSURANCE CORPORATION I HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING 1 MONUMENTA` ION ALL EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES, EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR COMMUNITY # 250167 SURVEYOR - -NOTE- - - THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY AND DOES NOT CONSTITUTE A PROPERTY SURVEY of - MORTGAGE LOAN INSPECTION PLAT - RNLlkLL NOR`.PHAMPTON, MASSACHUSETTS IZER PREPARED FOR +35Q32 JAMES YURGIELWICZ & NANCY J. MILLER SCALE: 1 " =50' JANUARY 10, 1996 3� HAROLD L. EATON AND ASSOCIATES, INC. REGISTERED PROFESSIONAL LAND SURVEYORS • 235 RUSSELL STREET - HADLEY - MASSACHUSETTS