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11A-016 .= BP- 2010 -0343 GIs #: ;. COMMONWEALTH OF MASSACHUSETTS 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- 2010 -0343 Project # JS- 2010- 000464 Est. Cost: $4000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. 1): 38855.52 Owner: PARK SOVINA Zoning: URA(100)/ Applicant: PARK SOVINA AT. 48 EAST CENTER ST Applicant Address: Phone: Insurance: 48 EAST CENTER ST (413) 320 -2670 () LEEDSMA01053 ISSUED ON :913012009 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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 9/30/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo r City of Northampton Building Department 212 Main Street Room 100 c ' Aorthampton MA 01060 phone 413- 587 -1240 Fax 413- 587 -1272 APPLICATION TO-CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING S TION 1 - SITE INFORMATION 1.1 Property Address This section to be completed by office Map Lot Unit Zone Overlay District EfrriSt District CB District SECTION - PROPERTY 'OWNERSHIP AGENT 2.1 Owner of Record f m (Print) Current Mailing Address: Csi t_:�;) 3 _) > - 2 (Q , Z L) _ Telephone Signature 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION -ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant I Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from 6: 3. Plumbing Building;PermitFee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2+3+4+5) Check Number This Section ForOffcial Use Onl Date Building Permit Number. Issued: Signature: Building Commissioner/inspector_of Buildings Date x . 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 Side L: ____ R Rear F Building Height Bldg. Square Footage _. ? 0/ -- Open Space Footage _ % (Lot area minus bldg & paved F p arking) # of Parking S aces - - -. •• -•- Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW 0 YES 0 IF YES: enter Book Page; and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: `T" D: — dre there any proposed ° changes o or a Iti o signs it termed for the property ? YES 0 NO 0 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 0 NO 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors 17 Acc ssory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [0] Other [0] rief Description of Proposed y Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa. If.New or cltl> #lor to'ezi.5 #rna° ©usinct, oiriptete` he- - If ©16auvW": 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:- T4 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 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 pe ury. Pri ame Signa o caner gent Date s SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9..Re'ctstered Horne- linp�roireirientuntrcto T,., ;! ..:. Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25CM) 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 exten to 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 o-f 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 dfffi amp on r tnanc s, a tts General -Laws- Annotated. Homeowner Signature a The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washin Street Boston, ALL 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumb.ers Applicant Information Please Print Lejibly Name ( Business /Orgmdmtion/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. [] 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. Ej Remodeling ship and have no Ioy ees These sub - contractors have. .8. ❑ Demolition working for me in any capacity. employees and have workers' P ac 9. Q Building addition [No workers' comp. insurance comp...ins nce 1. re ed 5. F We are a corporation and its 10.Q Electrical repairs or additions m- ] o cers haven �TS1�ec t}ieir 1I -am ��omeewaer�em all -werk- - - -- _ -- — AD- ghunbing ;epatrs or additions myself. [No workers' comp. right of exemption per MGL 12.O.Roof repairs insuran required_] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.} 'Any applicant 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 wont and then hire outside contractors must submit a new affidavit indicating such_ IContractors that check this box must attached an additional sbeet 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 work=' comp. policy number. Iran 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 MGL c. 152 can lead to the impositi on of`crimmal 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 , re of up to $250.00 a day against the violator. lie advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coveraee verif cation I do ereby _certify under thapahts and penalties ofpedury that the information provided above &&ue_and-correct__ mature: Dater _.- Phone #: C41 �) 2 , ff Y mp ed y city or town o fficial D� u:ial use oril : ,Do not rvrrte in this area to be co City or Town: Permit/License # Issuing Authority (circle one): - -1. - Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing 6. Other Contact Person: Phone #: 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 r- gullations The in= ction p =r equires that the building department be calle inspect work at various stages, which include foundation /footings (before backfil), sonotube holes (before your) 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_bu 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 J 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. Address of work location `V MA