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17D-163 it' i)( 1•=i, 1.i t 141111,111i:1 101017 RF,WS ANDREW DEREN• 396 ROCKR1MMON STREET BELCHERTOWN, MA 01007 " 11: 101017 , 1 Board of Building Regulations and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 11(mle Improvement Csontractor Registratioo Peq .str alon 1353'99 T DBA E xratcn 4 . 1 , 2010 Tr# A & J HOME IMPROVEMENT ANDREW DEREN 60 WASHINGTON AVE. SO, HADLEY, MA 01075 pdate ‘ddrcs. and return Al ark reason for chant. ‘ddrev. Rcno% al F mplo■ mum ost ( a rd 1 -1 1 op ID Lt. i OA/ 4:4 ‘14. 1 ACORD CERTIFICATE OF LIABILITY INSURANCE AJHOM -1 1 C8/23/09 _ - , . , r , ::.".J4.,•1.,..4A 4 i HS CLRHHCATF IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO BIGHTS UPON 71--)E CERTIFICATE Rerr,i 1 and 1 iocy, Tric ■ I ICLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 9 T.- ;.:;tre.et. ; ALTER I LC)LHAGE AFFORDF11 HY THE POLICIES L3EL01. 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LEFT II IT FAIT 114 40 140 SO SHALL 4nyty per '..tt !L. to.:Lr.tA itor, l' A tAy i c. 4. 1-- rl`a'r ,, r; , 1 4 4 '04 T(443 INSUREF, ITS ii4A I 'i '744 :.! 1 _ ___ ___ _ _!,,,.. __ ACORD 251200'10/ , 31 u)ACCRO CC)RPORATION 1988 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 regulations_ The insn ection process requires th at 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- injunction to the_builsling`permitissued,. 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. Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents ? Office of Investigations • ilV ' a 147 1 e g 600 Washington Street • a = . Boston, MA 02111 �� . www.mass.gov /dia . -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): A647 1-1 r Address: (O i4 c\ �, % , ,,L, sr\5 k d,r\ A i . City /State/Zip: ik.T brANA Clc\ . (3 1015 Phone. #: t i 1-. — t tE) - 1 13 O Are you an employer? Check the appropriate box: Type of project (required): i' 1.`v1 � I am a employer with �- } 4. 0 I am a general contractor and I 6. 0 New construction employees (full and/or part- time).* have hired the sub contractors listed on the attached sheet. 7. 0 Remodeling 2.0 I am a sole proprietor or partner- ship' amt have. no - 'p1oyees These sub - contractors have. 8. ❑ De aolon for me in any aci employees and have workers' working y caP ty 9. 0 Building addition [No workers' con:p. insurance comp. insurance_$ required.] 5. 0 We are a corporation and its 1010 Electrical repairs or additions 3.0 I ana a- homeowaer--da work- deers have x . . i —1-1.0-Plumbing -repairs or additions myself [No workers' comp. right of exemption per MGL 12.2t Roof repairs insurance required.] t c. 152, §I (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 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. Iam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site formation I n s u r a n c e C o m p a n y Name: Z `2 t cL-... 41''1 P ,c ', (Iv \ .LYS S , G C�,,,r� Policy # or Self-ins. Lic. ;#: 0 `'j S 1 CA '' 1 d. -. 09 Expiration Date: S 111 3 G 1(3 Job Site Address 1 1 k r)'Z - E ► 0 rk stKCL " & City/ State /Zip (. )9K'+‘ c, Ov C I 01044; 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 f ne 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 fTe of up to $250.00 a day aga Clip violator. t e advised that a copy of this statement may he forwarded to the Offine of Investisations of the DIA for insurance coverage verification I do hereby certify under the pains and penaltios of perjury that the information provided above aims and correct _- __ Si gna t ure: t- D ate: i 1 0� 0 " 1 . . • Phone #: 91 —tf 6'"1 --- 1 5 Official use only. Do not ►vrrte in this arena to be comp red by city or town gfftcaL City or Town: Permit/License #__ Issuing Authority (circle one): -`1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Ins ector 5. Plumbing Ins. ector ___ 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : ("\ Q %.4 C-S 3L 101°11 License Number *9 \ � ,��f'1 ( ��� ' � k k c Z r ILA a O ) Address Expiration Date 1 113 Lit 3- (SOO Signature Telephone 9. Registered Home Improvement Contractor , .'; 247 .... ;2 , ... 7 Not Applicable ❑ 3 <ove (1 L 3 . 1 r \ ) 3 s - 3()`) Company Name Registration Number w fr . h..A. sot►, X1 +1 (-)t© - '5 y (1j ao Io Address Expiration at ( Telephone 1 3 �— I I t.0 I— 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 112 No 0 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, 01 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 o ampton erg trances; a - = • „ . . - s- GeneralT.aws-Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 14 Or Doors ❑ Accessory Bldg. ❑ Demolition El New Signs [0] Decks [EJ Siding [0] Other [0] Brief Description of Proposed c 4 Work: Sit( k v1r � ti Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes z No Plans Attached Roll - Sheet sa If New1house and or addition to <`existing housing, wine : a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: 5 Number of Bathrooms 1 c. Is there a garage attached ?: f\C- d. Proposed Square footage of new construction. Dimensions e. Number of stories? ' `S 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, , 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 w :11 qc,t;-} U, r l , 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. r p Print Name Signature of Owner /Agent Date • z E 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 _. .,_. Building Height Bldg. Square Footage . % Open Space Footage (Lot area minus bldg & paved ._ . parking) # of Parking Spaces — - ..w. 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 0 DONT KNOW YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are t ere any d changes to or ad rtt f signs intend or 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. City of Northampton �� �e>i ? 1 7' B Department c u Cta#/ _ )e nrt t 00 • 2 Main Street 0801 ultty x ` Room 100 /'Northampton, MA 01060 a ?- ' r m an p.ohe 413 - 587 -1240 Fax 413 - 587 -1272 °` E 7.44, APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORMATION This section to be completed by office 1.1 Property Address: Map Lot Unit kf ■k ,cvr, fA C � G i 0E Zone ` Overlay District EIm St. District CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Name (Print) Current Mailing Address: ; 3 3 `�ti " - s• c Telephone Signature 2.2 Authorized Agent: l � , t {- ( ��j j'�) (5 _ 4 _ \ v�le � � *�� ( ~ in ' ` , � J„ �c � � U� 1 � �1 . `e, �� Of ' � Name (Print) Current Mailing Address: `La r' 13 - 15vO Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building O$ O (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Constriction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total (1 +2 +3 +4 +5) Check /410 3r*" This Sec on Far Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings; Date • • • • WdARYIELb ST BP-2010-0485 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17b - 063 CITY OF NORTHAMPTON f_ot : -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 -0485 Protect # JS- 2010 - 000668 Est. Cost: $4080.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: A & J HOME IMPROVEMENT INC 101017 Lot Size(sq. ft.): 7492.32 Owner: SCARBOROUGH VALERIE V /mime.: U1211(10(1 Applicant: A & J HOME IMPROVEMENT INC AT: 11 GARFIELD ST Applicant Address: Phone: Insurance: 60 WASHINGTON AVE (413) 323 -7847 WC SOUTH HADLEYMA01075 ISSUED ON :11/2/2009 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: I3uilding 11/2/2009 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo