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23B-101 1 %..• 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 - • 1 • - . • • • • - s 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_conj.unction_to_ the_ building _p -ermitissued,- 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 oflndustrial Accidents �11� Office of Investig,ations Ilt 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): f2&a',44= "17041 t L ' Address: 7 6 2.4 r • . City /State/Zip: /'v K i n /4,4 Phone. #: q/3 s‘? 7 V 3 Are you an employer? Check the appropriate box: Type of project (required): / 1. MI 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 2.9 I am a sole proprietor or partner- listed on the attached sheet. 7. © Remodeling ship and have no ft- ployees These sub - contractors have. .g. 0 Demolition workin g any ca: for me an tY employees and have workers' capacity. 9. 0 Building addition [No workers' comp. insurance comp. insurance. . required.] 5. 9 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am -a emeowser -doing- in Qbac_e_rsJ excised heir —I-1.0 Plumbing repairs or additions - - -- _ __ -_ myself No workers' comp. right of exemption 'per MGL 12.0 Roof repairs insurance required.] t ' c. 152, §1(4), and we have no employees. [No workers' 13.E1 Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infomation. 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. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: c . r #e,f'v< ( • Policy # or Self-ins. Lic. #: 7 ? T243 °-) 5 YJ i1t /3 / ti Expiration Date: /2 ‘/2 ' Job Site Address /Ye A/ fin? 5' City /State/Zip v N ri • e44 . °' l k u 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 fi e of up to $250.00 a day against the violator. I4 advised that a copy of this statement may be forwarded to the Office of Investi.aations of the DIA for insurance coverage verification. Ido hereby certify under the pains and penalties of perjury : that the information provided above_islrue_andcorrect. Signature: Date: 2/5'/ °i `' ) Phone #: =i12 - F7 - 0 4-/ 3 7 Official use only. Do not write in this area; to be cWmple 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 Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : t ", - 14. / , y V,n'41 v' (' S - 413 C• License Number 3.1 v 2t7. -' i j) ,A&r`7-//47)'I �J . -1/a c��J l j,ZS I2o Address Expiration Date —►).._ - Y/3 - G S Signature Telephone 9:,.Registered >l• orna iti4overneritContraictts ... , .n ,. E Not Applicable ❑ DE40 . G CC / SI (v/l Company Name Registration Number 76, 3,4vc od r 07 A/j,es #MDTa , i•t4 O r'y 6U 6/6/2110 Address Expiration Date Telephone `f" ` °y 3 7 _ SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6» J 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 Af No ❑ 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 Or mane s a e - • • - s- General -Laws- Annotated. Homeowner Signature . .• 1 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House [l Addition El Replacement Windows Alteration(s) ® Roofing Ej Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [El Siding [O] Other [❑] Brief Description of Proposed. T Work:_' 4- VE 7)rf,elraan✓ s✓.ntc a,J / S' 14)4' f- /,./..3-1 .,�15-1rr/7 c.e62,eyi�5 f2',,.4 ,4 -5 ,PP3 4 eec Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll - Sheet 6az if ew h6tiika d d d lirtiVi xistifid*bUilfa.AlilAte. ii W ltowinq: 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 1 ?ow (�- p�-(�1�� P1 S ` , as Owner of the subject property hereby authorize Ed `4 E ,V,W //4'v' to act on my b If, in all m rs relati e work authorized by this building permit application. Signature of ner Date I:d L Ei/,f /y J , as 9woer/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 't--- `7, i e 2 /3 a Signature of AwliedAgent 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 i J ? . _ _ _ V _. _._ Setbacks Front . .. 4 Side LF - -' R ._.. ..j L: R Rear [ 1._. . Building Height ° r , Bldg. Square Footage t I % i 1 Open Space Footage % r (Lot area minus bldg & paved parking) # of Parking Spaces — .. Fill: I }1 (volume &Location) — - 0 t---. - ---_- i i 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 l Page 1 and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO Q IF YES, describe size, type and location: D. Are there any _ proposed to or ad l n s ns interred Tor the property YES 0 NO 0 z - g P P y� 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 = �� Building Department 1 - 212 Main Street Room 100 Northampton, MA 01060 a i e 413 - 587 -1240 Fax 413-587-1272 Pet a ate APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION CB 1 0 010 1.1 Property Address: Thi secttion to be completed by office i ' e e s , A/ /c N % ir/7 5� Map Lot — . knit Zone ` Overlay District Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: - n Name (Print Current Mailing Address: 4 1/3 — S -- 96 Telephone Signature 2.2 Authorized Agent: -Id L 7 (, 73 Ale e<3` � e77-1 4p7 , -r,wt Name (Print) Current Mailing Address: --- 41/3- 65C-366 2- Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building rQ (a) Building Permit Fee 2. Electrical .� (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. 0:3 . 1 J . Total = (1 + 2 + 3 + 4 + 5) (, Check .Number This Section For Official Use Only Date Building Permit Number: Issued. Signatures Building Commissioner /Inspector of Buildings Date File # BP- 2010 -0722 APPLICANT /CONTACT PERSON ED LENNIHAN ADDRESS /PHONE 76 Bancroft Road Northampton 587 -0437 PROPERTY LOCATION 188 NORTH ELM ST MAP 23B PARCEL 101 001 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 Fee Paid 4/ /� Typeof Construction: REMOVE 1ST FLR WALL & INSTALL CARRYING BEAM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 042506 3 sets of Plans / Plot Plan /JEE: j t36 6 Ff (R e.-(7S l Re° LA-5 * 1 596Grte tJ THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION PRESENTED: proved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan ANI) /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 �/► � 1' - 212,21 L O 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. 188 NORTH ELM ST BP- 2010 -0722 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23B -101 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 -0722 Project # JS- 2010 - 001075 Est. Cost: $4000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ED LENNIHAN 042506 Lot Size(sq. ft.): 14636.16 Owner: STRAMESE PAUL Zoning: URB(100)/ Applicant: ED LENNIHAN AT: 188 NORTH ELM ST Applicant Address: Phone: Insurance: 76 Bancroft Road 587 -0437 WC NorthamptonMA01060 ISSUED ON :2/22/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REMOVE 1ST FLR WALL & INSTALL CARRYING BEAM - NEED BEAM CALCS AT RGH INSP 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 ? /2 " House # Foundation: */4/ Driveway Final: Final: 743 Y, , Final: 7�/0 / 7 - Rough Frame: / j I , t C., , 'It MO1 ty'S`rep 01 % 5 1 a 0.41444". Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Fina1:7- /.5 2-4. Smoke: Final: pi< ‘57.. 2 ()-id C :VN1..- THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIO 4 ON OF ANY OF ITS RULES AND REG , , 0 0 • re Certificate of Occupancy . 1 ' nature: FeeType: Date Paid: Amount: Building 2/22/2010 0:00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo