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41-017 (8)
„ 0c%by s a •g' � /►'I � � tI ),t j 1 3 1 V . . . a b9-z) vv./0y daaetruit � a + • k, • � � P - I9'1 1 ` 4 5 s • 41 -. ,'.‘.-„. 1111SA;41;;1 '44,, -.., :A/ .. .. '41 14:14.' i ,.T: . - '''';), - ,'' , ,-4! VI, ...* .„,_ ..r. "kik , i . . r ' '-;..-', i' -, . . ' '''-' . _.. .44 . -...,:. ;I tt, tO . : II 3 e; 5 �� fix ° Jr, rid I i ttil..7i ("PUN Mrs i , ! } y. - ' ,,,, 'y y y ^4 ,mil WAIN' • 1� .. t” , : � 11 ''',•:', N .. fk � .1 tl4 fi l� d 4F4 � CICICA/1 fl '4r:li 47t ,. S, . M1 a of 'si , N i 't - o . ,! h r : _..• a: ,, ? r$4 �'A . hg` ii elf4'a' AA ��,��, �,,.`` 11 ! r -off i s o - 9' b 'w w.�'.. � , mow s r L 1 C - ' [4r` I 4 '71F�✓ti' G• A. s � • '#• ■ L "`d •#�4+ - M "t + +9,1..59 !!/` t "'•' Ca'4� ■. ANC 6 ! t r y .lyr 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 to Date Address of work location . , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations • 'i; = - 600 Washington Street .. —... — , Boston, MA 02111 --..- , www.mass.gov/dia , a:. • -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name pusiness/Otganization/IndivicinAD: " / "7, / Address: /'2-2_ 4l.-C,1 r ' - ----- City/State/Zip: (/' Att (7), Gk Phone.#: 1/45 7$ - 71 Are you an employer? Check the appropriate box: Type of project (required): 1 7 • 1. 0 I am a employer with 4. 0 I am a general contractor and I 6. 0 New construction I.,... .loyees (full and/or part-time a sole proprietor or partner- ).* have hired the sub-contractors 2. listed on the attached sheet 7. 0 Remodeling am ship and have no employees These sub-contractors have 8. 0 Demolition working for me in any capacity. employees and have workers . - 9 EjBuilding additirin [No workers' comp. insurance -. comp._insurance.;__ . required.] S. 0 We are a corporation and its 10 Electrical repairs or additions 3. 0 I am a homeowner doing all work officers have4xercisecl their . 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.17 Roof repairs . 1.....1 insurance required.] t c. 152, §1(4), and we have no I employees. [No workers' 13.E Other comp. insurance required.] , *Any applicant that checks box #1 must also fill out the section belavv showing their workers' compensation policy information_ 1. Homeowners who submit this affidaVit intficating they am doing all work and then hire outside contactors must submit a new affidavit indicating such. 1 Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not ;hose entities have employee& If the sub-cmtractorshave employees, they must provide their workers' camp policy number. . Jam an employer that is providin' g 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 n umber and expiration date). Failure to secure coverage as required under Section 25A 'of MGL c. 152 can lead to the iirciositieri 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of EV Of the for iiiitiratice cOviiiie iiiiifiiiiiiin _ . . ..- , - . „ , _,-, _ I do hereby_ certi der , thepauzs'andpesain5s ofpedzay that the infornuttionprovidedabove_isinze_and_correct.______ _..... . • ___ . . . Sianature. ' Date: • , Phone ii: 5 ( - 7 7 - - • • • Official use only. Do not write in this &ea, lb be completed by city or town officzaL . City or Town: .- Permit/License # .......-----..— ... Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Insj)ector 5. Plumbing Inspector 6. Other , I- • Contact Person: Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction S perrv ( Q / � Not Applicable 0 Name of License Holder : � v ' / / 5 I a / �^ I �l 7 License Num r Address Expiratio Date S• signature Telephone . j� Not Applicable ❑ 9 : :.Realsteie�.Home�lmp :. yerrient`Co ' c�ar•,_ �,.,..,�. ��* ..�.�.�a � � � .z � . .; pP ,l ototvey � � s i ! /cN N bm 7 3 Company Name Registration ber 112- tv.e 5 7 l�// '"-I //L 1 .7 � // Address Expira o Date Telephone 5757z, 7( ( a, (C — 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 ❑ 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 l provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3 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 buildine 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 State of Massachusetts General Laws Annotated. Homeowner Signature ., SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ES Replacement Windows Alteration(s) ❑ Roofing Or Doors al Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [Z] Other [D'] Brief D9scriptioII of roposed, ) [ /, / Work:. Qy✓rxib /f 4�yry►< o WCS r)4 /Gi� S / / � , ,I G G1 . StctSJ4'P Alteration of existing bedroom Yes ✓ No Adding new bedroom / Yes V No Attached Narrative Renovating unfinished basement Yes L- No Plans Attached Roll I-1- Sheet sa3fit"ew.fiotiieliiii ; cr kftifikrr.tc Vii iiti a iiiiTi iiiiii it fi itcw np: a. Use of b•' •ing : One Family l/ Two Family Other b. Number of roo in each family unit: Number of Bathrooms • c. Is there a garage a hed? % d. Proposed Square footage 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 w- ands? Yes : Is construction within 100 yr. floodplain Yes No j. Depth of basement or cell- oor below finished grade k. Will building confo • the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Suppl ._. ___.._ .................. SECTION /a - 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 I, , as er /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the bas f my knowledge and belief. Signed under the pains and penalties of perjury. a il 4 / 24 7 " PrirtCName i 11 I ,. /4 CI G /'h� 4) * fl 0 "7 — �� p9 � oho M of Owner /Agent 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 L ot Size l _ _ _ _ Frontage ► ._ --... Setbacks Front 1 5 O - = 11 �? Side L:T v ' R:i L:.. # ' : t 1 L.,..___ ..s Rear ,/ UO r..i� 1 Building Height i I r j I I Bldg. Square Footage i % 1111111V i i € Open Space Footage % I 1 ( jrni Lot area minus bldg & paved I .. , ..-_ parking) t # of Parking Spaces_ I , — Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW ) YES 0 IF YES, date issued:; a IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 i IF YES: enter Book F P age l I and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES x IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued o C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES © NO e ., IF YES, describe size, type and location: l 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 fo IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton St > Building Department k" ' 0 f 1 212 Main Street - >. ° �` . , Room 100 : - ,. 4-pr : � `� . 2010 Room MA 01060 f da e 4,04 ' phone 413- 587 -1240 Fax 413 - 587 -1272 14� APPLICATION TO CONSTRUCT, ALTER, 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 / 9 / ( ?A_ • Map Lot Unit 0 Zone e is 'et Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 0/06a A /buff A ChQ mpa) h€ 3" le // C7 / Wecf'4 a ni takt Rol, #0)1 lie Name (Print a Current Mailing Address: y/? ice 6 G 6 /.S' Telephone Sig tun: " ---- " id(4 1 21 1 " i 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone i SECTION 3 - !ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 4' /0 000 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4 5c, 00 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) Check Number / This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2010 -0849 APPLICANT /CONTACT PERSON RONALD MISTARKA ADDRESS/PHONE 122 WEST ST WEST HATFIELD (413) 575 -1271 PROPERTY LOCATION 1194 WESTHAMPTON RD MAP 41 PARCEL 017 001 ZONE RR/WP/WSPII THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 11 56"-- Fee Paid / Typeof Construction: CONSTRUCT NEW GABLE DORMER (WESTSIDE),INSTALL SKYLIGHT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 069836 3 sets of Plans / Plot Plan THE F 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 Demolition Delay *f i/ to 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. 1 94 WE a . ; .. F,.. BP-2010-0849 GIS #: COMMONWEALTH OF MASSACHUSETTS Mai:Nock : - 617 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 -0849 Project # JS- 2010- 001262 Est. Cost: $10000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RONALD MISTARKA 069836 Lot Size(sq. ft.): Owner: CHAMPAGNE ALBERT A JR Zoning: RR/WP/WSPII Applicant: RONALD MISTARKA AT: 1194 WESTHAMPTON RD Applicant Address: Phone: Insurance: 122 WEST ST (413) 575 -1271 WEST HATFIELDMA01088 - 0519 ISSUED ON:4/1/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT NEW GABLE DORMER (WESTSIDE),INSTALL SKYLIGHT 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: FeeTvpe: Date Paid: Amount: Building 4/1/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo