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16A-020 (2) t 4fi> CJ = . . .., ' f . „.."' Z 4, /..-1 /1 .--- \\N " . " - -, \\ \\ :IL- '''N' 7 SI \\I ' -' ' 'A \i's; --'' 1 -� 1 1 9� ti Q 6)\ , \\I o C \' \ z...,,,------ 0 4- 4 , , _____----— --, —.7,______, _\\\, 1 i DEPARTMENT OF BUILDING IcvS?ECT IOONS ry ° = c I NS P ECTG2 212 Main Strtet • Municipal Building Mort mpton, MA 01060 HOME OWNt' EX 4 C7 NOWLEDGFMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sups 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 fwnily 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 ofNorthampton wants any person(s) who seek to use the horie owner exemption, to act as their own construction super visor 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 backfilI). so-notube holes (before pour). a rough building inspection (before work is concealed) insulation- insoecti.an (if required.) and_afnal b s • a insnecti.o.n. 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 uI-- the - work -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 • 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 • . '.'°., The Commonwealth oj7Iassachnserrs .Department of Irdusrria%_4ccidents " wr Office ace of Investigations c 5, r- - , ;;, 600 ;h� ash ir.° on Street Ck ^-- Boston, 4 02111 www.mass.gov /tea Workers' Compensation Insurance Affidavit: Builders /Contractors/EIectricians /Plumbers Applicant Information Please Print Leo Name ( Business /Orcat:ization/lndividzzal): 4 6 F Co/l/ S T/2Ve..--1"/` w Z- C Address: 3 S f f I� �// T P 0 /ac7? — Ca Cir f 1G 1 es'2 - rrat, -' 44 Phone , q/� ® � 6 ? I Are you an employer? Check the appropriate box: f I Type of project (required): 1. ❑ I azn a employer with ?- [—� I am a Gene -al contractor and Z Y have hared the sub- contractors 6. El New coBStrucnon ii�-� employees (full andlor part- time). 2. ` I I am a Sole proprietor or pa_*taer hsed on the attached sheet 1 - �1? e pdelinv J sbi and have no --ploy ees These sub- contractors have ii g 0 Demolition working for me m an capacity. employees a h ave workers' rlcr� y 9 0 Building addition f comp. insurance.- I [No woke =s' co. ;^s-uTance required.] 5. We are a corpora ion and its 10.0 Electrical repairs or additions 3. ❑ I alit a homeowner doing all work officers have exercised then 11.❑ Plumbing. repairs or additions mvse jIv o workers' comp. right of exemption per MGL 12 Q Roof repairs insurance regtzi ed ] t c. 152, §1(4), and we have no employees. [No workers' 13.0 � comp. insurance regtnred.] - - -- v applicant tnat ,:ate aoz ;r must asp till 011t Me sc:aon aelow snowing the won='' compe:manon.policy mforsmnoa. - - -- 1 Homeowners wino submit this affidavit indicanns they are doing all work and then hi: a outside contactors must submit a new affidavit mdica ng such_ :Contactors that che± this box must- arrrhed an additional sheet showing the name of the sub coana=o s and szte whether or not those entities have empioyees. If the sub- conaacrars -have employees, they must provide thef woriccs' corm. policy numb . 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. T: Expiration Date: Job Site Address: _ City, /State /Zip: • Attach a copy of the workers' compensation policy declaration page (showing the policy number and ex piration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the irmosition of criminal penalties of a fi up to $1 and/'or one -year imprisonment, as well as civil penalties in the form ofa STOP WORK O_RD�R and a fne 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 Investicadons of the DLA_ for insurance coverage vacation. I do hereby certify tt • er the pains pen ties of pe, jury• than the information provided above is true and correct =r?an re / * — }--- -- — — — _ Date: D A— V, (-0 8 Phone #: 'if/ . j"r‘ a O9c• vflz use only. Do not write in fitly area, to be completed by dry or town official. g. + � p City or Town; __ L? -�1�"- ru;i#/License � Issuing Aut+�ioriry (circle 1. Board of Health . Building Deaartmer 3. City/Town Clerk 4. Electrical Tnspector 5_ PIumbing Inspector 6. Other /' Contact Person: 4 ,L j -a Phone #: 5e2 - /z 4/0 SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ ! Name of License Holder : `O 41. .5 / O,'& l/ ` 7" /'C / s7C o ` 7 License Number -3 Z, o4 -(iAe/ /4 rN, ie d , t0 -/? -200g Address Expiration Date I We tV14 4 7 - -e // M^- 0l0 3 9 Signature Telephone e//3- 1-c0 -- Y4/95— 9. Registered Ho a 1m.provemt en Contra Not Applicable ❑ .i/ - ? e_ O ^ ✓ f Di< ci - rf ON L 1- C l V 1 ( f g Company Name Registration Number Address Expiration Date , r� 3 1 - s ° /J t f e e, e/'2 ro c4.44' ,��' s7 Q / 0 b 7 v� Telephone to � 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 ❑ 11. }To/lie-Owner Exe on 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 -vear 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 Local Zoning Laws and Slate of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House n Addition ❑ Replacement Windows Alteration(s) ®-- Roofing n Or Doors El Accessory Bldg. ❑ Demolition n New Signs [❑] Decks [Q Siding [❑] Other [❑] // Brief Description of Proposed ` __ 11-e / c_ - tN ` .- 1"P T re' r 4 Work: "P,"@ �Y' I /1445 - rT62 Vl ;6"'"145 ,-," .01 l to e' rti Alteration of existing bedroom Yes ,-/--- No Adding new bedroom Yes r No Attached Narrative Renovating unfinished basement Yes h No Plans Attached Roll - Sheet sa. if New`hous or addition to exist i4 housing, cornpl the following: 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 I �� i/X .'t 6(/ '#) / , as Owner of the subject property // 1 hereby authorize 4f e or* 57 nU� = TI t a� C- 0 .m4 /O el l r f �i 1 to act •n my behalf, in /Il matters relative to work authorized by this building permit pplication. ii (_(��, — — , 7 ./ / ,, 0 g S nature of Owner Date I /�d at. i 4,1' Y ro_.4 v- 'l ._ f Z LaA cc tta , as Owner /Authorized Agen hereby declare th the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pain and penalties of perJury.� / P t Name K Signs re ofwner /Agent Date r • 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 _____ ... ... Rear . ,_ .. „_..,. ......_..._.. Building Height ._.... Bldg. Square Footage % ... 1 Open Space Footage (Lot area minus bldg & paved narking) I r # of Parking Spaces • -_..__ -- --- _. _. Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 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 Q DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO Q 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 c.ur rtrrron 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. 4 Departme City of Northampton nt use only Status of Permi #: Building Department C urti Cut/Driveuay Permit 21,2 Main Street Sewer /SeptcAvaty �� �� L r l� ( � \ Room 100 water/Vrell North mpton, MA 01060 T vo Se ts of Structural Plans`; I— - polo l 3 -587 -1240 Fax 413- 587 -1272 Plot/Site Plans I 1 ' r t'''') .. Other Spe ?pL�CATIOhfTp COI 91 UCT, SALTER, 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 / _ 0 Gt '�,st i 2 ,¢�r l/ f r /iq .-e Map Lot Unit Ct / e _ k / 4 a / 0 5- '3 Zone Overlay District C% d 1 Elm St Dist CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner o.f Record: S� //% C v�W�/ 6 G J F4,, �Y (/' / /'f C1 / Name Qf' . nnt) Current � Maili� n ddress: �.� s 3 ilk _.�i��f. f� en Telephone ir /( U Z U Sig ature - / `�' � 2.2 Authorized Agent: Q ``QOM /o/� Yr° s ,` 37 r<1� / 7i/7/ _ X) - Name (Print) Current Mailing Address Sign re Telephone ell— a C SECTION 3 - ESTIMATED CONSTRUCTION COSTS 1 Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building - 3 6 (a) Building Permit Fee 2. Electrical / 5 © G (b) Estimated Total Co of Construction from - (6) 3. Plumbing qc) O f"7 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 414-- 6. Total = (1 + 2 + 3 + 4 + 5) / Q Check Number /r;1 'y % This Sect ForOfficial Use On Date Building Permit Number Issued: Signature: Building -- Commissioner /InspectordBwldings Date File # BP- 2008 -0712 APPLICANT /CONTACT PERSON THOMAS KORYTOSKI ADDRESS /PHONE 359 BARDWELL ST BELCHERTOWN (413) 323 -4393 0 PROPERTY LOCATION 608 FAIRWAY VILLAGE MAP 16A PARCEL 020 000 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �}��� Fee Paid A3.3 ?t6 Typeof Construction:_REMODEL MSTR BATH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildin2 Plans Included: Owner/ Statement or License 070047 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOXVIATION PRESENTED: Approved Additional perrnits 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 ,,, Demolition Delay ,,,.„.-,,,e----7:7-)11------ .2../ B Signature o 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. BP- 2008 -0712 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -000 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2008 -0712 Project # JS- 2008 - 001105 Est. Cost: $9100.00 1 00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THOMAS KORYTOSKI 070047 Lot Size(sq. ft.): Owner: CONWAY SALLY ALICE Zoning: Applicant: THOMAS KORYTOSKI AT: 608 FAIRWAY VILLAGE Applicant Address: Phone: Insurance: 359 BARDWELL ST (413) 323 -4393 () BELCH E RTOW N MA01007 ISSUED ON:2/28/2008 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL MSTR BATH 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: FeeTv'pe: Date Paid: Amount: Building 2/28/2008 0:00:00 $50.001033 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo