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23D-026 —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. - BUILDING LOCATION ACCURACY IS NOT GUARANTEED NOTE: SUBJECT TO EASEMENTS AND RIGHTS OF WAYS OF RECORD. • 80't 10 ) B OK t969, RAGE 331 GARAGE BOO 655, PAGES 250 -251 LOTS #27 -28 / i 1 � 35 PoS� 0 ?z....._., • Q �J Q 0 #480 f II BIT. 11 CONC11 1 ,Ii 1 - 11 t '' 80't ELM � STREET ____ TD. FLORENCE S AVINGS BA RAND K , AMERICAN TI'S INSURA CE COMPANY TO THE BEST �_ ' i' MA a a ON NOW ,E AND B HEREBY REPORT THAT 1 HAVE AMINEO THE PREM ISES ANO BAS O N EXISTING tJMENTAT#ON ALL VISIBLE EA MENTS. ENCRO ACI-?ME TS AND B ;ILD NGS ARE LOCATED ON THE GROUND' AS SHOWN AND THAT THE BUILDINGS ARE ENi7RELY WITHIN THE LOT LINES. 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. lithe 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, 0S �{ oft C►4? E I R "` erstand the above. (Home owner /resident's signature re. ing exemption) I will call to schedule all required buildin . nspections necessary for the building permit issued to me. Date /a /0 Address of work location ( r / k4 . S o ' _ The Commonwealth of Massachusetts Department of Industrial Accidents ` — Office of Investigations `_; 600 Washington Street Boston, MA 02111 www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians /Plumb Applicant Information Please Print Le,gibly Name ( Business /Organization/Individual): -G 1 t U4 - � f, � RcD Address: D E ) S i_ 7 — City /State /Zip: ))or -7 ,¢MP i j 0)060 Phone #: 1 ) 3 SST) `-( a `{ q S 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. ❑ Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. employees and have wurkers' [No workers' comp. insurance comp. insurance. $ 9. ❑ Building addition re uired. 5. [I] We are a corporation and its 10.0 Electrical repairs or additions q ] officers have exercised their 3. I am a homeowner doing all work 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13.0 Other employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I. 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. 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. #: 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 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 op to $750 00 a day against the violator. Be advised that a copy of this statement may be fonvarded to the Office of Investigations of the DIA for insurance coverage verification. - - I do hereby certi. , nde the pain , nd penalties of perjury that the information provided above is true and correct. Signature: 4 11P L A _ Date: Phone #: 7 Official rise 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 CIerk 4. EIectrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9. Registered Horne Improvement Contractor: 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 ❑ 11. ome, caner- xem ition 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 1521 (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 fui peisun(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifie and assumes sponsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Lo al Zoning La and State of Massachusetts General Laws Annotated. Homeowner Signature ` —� ,I SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House i l Addition Alteration(s) (� Replacement Windows Alterations n Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [ID] Decks [Q Siding [E] Other, Brief Description of Proposed f � n+ • �k Work: Cot V 4 -I — oat' V4MA 6£17 "DK Cl�. � F>E� emu. o n► a i Alteration of existing bedroom Yes Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes Plans Attached Roll - Sheet 6a. If Nevv house and or addition to existing housing, complete 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. Dimension e. Number of stories? f. Method of heating? Firepla.-s o oodstoves Number of each g. Energy Conservation Compliance. Masse. -ck nergy 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 d S Lf UA' c4R -r ) 1Z C7 , 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. os•1f�� C ; 6 R■Ti.) Ra Print Name I 0 Signatur er • nt Date • 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.. ,J_. R.,3 L:� ,__. _,'. R�._` Rear 3 30 Building Height� °' Bldg. Square Footage Open Space Footage /o . (Lot area minus bldg & paved � A parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW '41 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 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 0 NO * 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 IF YES, describe size, type and location: _� � __.,..__r..._. ._�.____._.�,...._...__..___� __ ,._•._. E. Will the construction activity disturb (clearing, gradin• excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Department use-only _._.._ -Cits of Northampton StatusofPerinit c lading Department Cur'b_Cut/Dnveway Permit II �I �� J -, 12 Main Street SewerlSeptic Availability . Room 100 WaterJWe11- Availability o 2009 Nol rlipton, MA 01060 Two Sets of Structural Plans 301._ - hone 41587 -1240 Fax 413 - 587 -1272 Plot/Site Plans Other, eci :is �. AFTL4 AT)ON TO,CO , ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: section to be completed by office Li go E1M S 1 Map Lot Unit �1 D 1 1-t-41-1 P taN �� 0 10� ® Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: St> s i+V A g C4'g E112 0 <;t1 4 ' j /Y Name (Print) r Current Mailing Address: '.() 3 S S 4 Q`4 9 S Telephone Signatu 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 p s - ' C9 a O (a) Building Permit Fee r 2 Electrical (b) Estimated Total Cost of Construction from (6) - 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Total 6. To 2 4 CheckNum = r C) ©d Number A.- s4 '--- This Section For Official Use Only Ruilding Permit Number: Date Issued. Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -0100 APPLICANT /CONTACT PERSON CARREIRO JOSHUA L & JENNIFER L JAKOWSKI ADDRESS /PHONE 480 ELM ST NORTHAMPTON (413) 584 -9495 0 PROPERTY LOCATION 480 ELM ST MAP 23D PARCEL 026 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Building 43 Fee Paid Typeof Construction: REPAIR TREE DAMAGED DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Demolition Delay Signature of 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.