17C-154 (3) RECEIVED ci;L_ cATIA--c-
1 t a - 32011
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N. DEPT OF BUILDING NSPECDONS
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4" X 4" POSTS TYP. ,_
CONNECTED WITH
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THREE 2" X 12"
STRINGERS
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88 HIGH STREET REAR PRESSURE TREATED STAIRJN.SE 8/3/11
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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
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 tome.
Date 7� /�
Address of work
location ,'8 ,4// 7 ' 5
r2b,, cg/1
. The Commonwealth of Massachusetts
Department of Industrial Accidents •
Office of Investigations •
g • 600 Washington Street
Boston, MA 02111
- www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information - Please Print Legibly
Name (Business/Organization/Individual): (E:7221./ cotz •
• Address: t gg' J4Q655
City/State/Zip: F / Phone.#:
i 1 / 4 °7°7.
Are you an employer? Check the appropriate box: 0 Type of project (required): 1/'
1.0 I am a emp w i t h 4• 0 I am a general contractor and I . • 11.1.ew co_ ton
have hired the sub-contractors
employees (full and/or j*
listed on tile attached sheet. 7. Remodeling
2. 0 I am a sole proprietor or partner-
• Ship have. no employees These sub-contractors have. 8. 0 Demolition •
working for me in any capacity. employees and have workers'
• 9. 0 Building addition
[No workers' comp. insurance • comp. insurance. • 10.0 Elect repairs or additions • required.] -. 5. 0 We are a corporation and its •
• 3.471 I am a homeowner doing all work officers have:exercised their • 11.0 Plumbing repairs or additions
• myself [No workers' cOmp. right of exemption per MGL
12.0 Roof repairs
ms urance requfrecL] t ' c. 152, *1(4), and we have no ik/ 577 •
employees. [No workers' 13 - 1 ZW' ther - -73( / /t16. (
comp. insurance required.] • *Any applicant that checks box #I must also fill out the section below showing their woricers' compensation policy information. : •
t Homeowners who submit this aiEda;it 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.
lam 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 crimin,11 penalties of a
fine up to $1,500.00 and/or MC-year imprisonment, as well as civil penalties in the form of 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 Offi'ce of
Investieations of the DIA for insurance coverage verification.
Id5li ereby certifr u e ern: ofpedury that the information provided ab o • is ue and correct
„?' z ,
ienature: 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 0 h- •
I Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicably ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
t " is ei aKprotreimon ;` ,. a,. .. .:.< Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M c31-. 0.152, § 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 0
: °9 l: like its; ° it it3 0i
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 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 onin La d State of Massachusetts General Laws Annotated.
Homeowner Signature
0
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 / 1 Q � � Siding [0] Other [0]
Brief Description of Proposed C
Work: �j9757I S7?' //Zt S F ci 6X t Gvl1/�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
Sa 0 r retina C ; r >f ,� 0 st .,. , tl tt4iiraSilWftfr
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. WW 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
, 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
it C7Vp
Signature of Owner /Agent Date
l
kir
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete fora tion ' '" "
}
Existing Proposed Required by Z .. , i
This column to be filled in 133+ i ce• r i
Building Department r9x
' Lot Size
Frontage __ 7
Setbacks Front 1
Side L:' I R:I l L:i R: _ ? 1
Rear = 1 I 11
Building Height J 1 1 3 1
Bldg: Square Footage 1 1 i % 1 1 I i ;
Open Space Footage % �? i — — -
ry
(Lot area minus bldg & paved [ ? j L. 9
parking)
# of Parking Spaces
Fi11:
(volume & Location)
It i
A. Has a Special Permit /Variance /Finding ever been issued for /o he site?
NO 0 DONT KNOW 0 YES
o
IF YES, date issued:I I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book I Page I 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 Obtained 0 , Date Issued: ` m__ mm
C. Do any signs exist on the property? YES 0 NO CV
IF YES, describe size, type and location: ,
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0
IF YES, describe size, type and location: 1
E. Will the construction activity disturb (clearing, grading, exc vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton ',,A04%.,-----1 ,n.
Build Department p ' ° » 1
212 Main Street m
_ . Of ���� Room 100
• �`'" Northampton, MA 01060 r�i
phone 413 - 587 -1240 Fax 413 - 587 -1272 , �� ' e All
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Propeer
This section. to be completed by office
f .� /# j Map a ' Lot Unit
��� �� J lr j 1 A
Z ar[ e w� Overla
E lrmi °S Distric CB.District
016 62
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record: 0JDi�
Name;' /,' , Current Mailing Address:
it Telephon J t3 9 ?z,
Signature / /((//
2.2 Authorized Agent
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building Building Permit Fee
g c� /(//j6c 7 000 , 60 (� g
2. Electrical (b) Estimated Total cost or
Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
gals �-
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings ! Date
l
File # BP- 2012 -0146 , .
APPLICANT /CONTACT PERSON COHEN EDWARD N & LYNN MARCUS COHEN
ADDRESS /PHONE 88 HIGH ST FLORENCE (413) 585 -9326 0
PROPERTY LOCATION 88 HIGH ST
MAP 17C PARCEL 154 001 ZONE GB/URB(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT _
Fee Paid
Building Permit Filled out - {��
Fee Paid �h
Typeof Construction: CONSTRUCT EXTERIOR STAIRS & REPAIR BALCONY
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Buildin• Plans Included:
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE FO LOWING 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 Commission Permit DPW Storm Water Management
! ey s io,n De y 17...„,c....,/
Si_ a of Buil. i fficial 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.
88 HIGH ST BP- 2012 -0146
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 1- I CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Bt' 'i_g ''O NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: renovatioi BUILDING PERMIT
Permit # Bf' 20124,146
Project # JS 2.012- 000183
Est. Cost: $1000.00
Fee: $110.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 1 ,0.72 Owner: COHEN EDWARD N & LYNN MARCUS COHEN
Zoning: GB/URB(1 Applicant: COHEN EDWARD N & LYNN MARCUS COHEN
AT: 88 HIGH ST
Applicant Addre Phone: Insurance:
88 HIGH ST (413) 585 - 9326 0
FLORENCEMA :10 (32 ISSUED ON:8/8/2011 0:00:00
TO PERFO:' ' ( i .'' FOLLOWING WORK: CONSTRUCT EXTERIOR STAIRS & REPAIR
BALCONY
POST THIS C. ? IS VISIBLE FROM THE STREET
Inspector of Plum, ,cctor of Wiring D.P.W. Building Inspector
Underground: rvice: Meter:
Footings:
Rough: ugh: House # Foundation:
Driveway Final:
Final: u1 l :
Rough Frame:
Gas: e Department Fireplace /Chimney:
Rough: i• Insulation:
Final: 'le: Final:
THIS PERMIT _EVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS R , REGULATIONS.
Certificate of 0 Signature:
FeeType: Date Paid: Amount:
Building i 2011 0:00:00 $110.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner