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23D-005 (2)
g li tL I •1 c LMca -1- 1 NI et141$ N ..._ , igvv.o..0 (3.))( e3NNZ k -. k e 1 vvv=iciat-i_wg • 3 ,„.=,:zrecp-st ....2. - D -. 7 - ) - Kr--7-4t - zra ( - z-r -- -Sti I`A 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 picess 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 — puts-- in- conjunction_to_the..building permit issued, 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. - -t Address of work location r Al- The Commonwealth of Massachusetts — Department of Industrial Accidents -pi. P Office of Investigations • w - h 600 Washington Street 7 .1*, Boston, M4 02111 ;,� www.mass.gov /dia -Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/Plumbers Applicant Information Please Print LegibIv Name ( Business /Orga z ation/IndividuaI): & 1 ' di . bk3 Address: _ _ -� - a_ i, . . T.' r11 t t< t G-1.1 4 City /State /Zip: li t j;i= tat,b biaG Phone #: qr3 S3 y- 5 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 * have hired the sub- contractors 6. 11 New construction employees (full and/or part time). 2.k I am a sole proprietor or partner- listed on the attached sheet 7. Remodelin ship and have. no P- rployees Th ese sub - contractors have. g_ Denio1it on capacity. employees and have workers' working for me in any P ty. 9. Q Buildirt • addition c ;assurance,: [No workers' insurance - � required.] 5. D We are a corporation and its 10.0 Electrical repairs or additions 3. I am- a -homeowaer- doing,-a11 work oe kershava e ise_d_their _ 1.0 P- lambing repairs or additions myself No workers' comp. right of exemption per MGL 12. Q. Roof repairs insurance required.] t c. 152, § 1(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. 1 Cont -actors 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 and/or one :year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification I do hereby certify under the pains andpenoltres of perjury that the information provided above_ is_true-arrdcorreci: Si • .. tore. -J VI W VAMI ,. '411' , .F e. Phone #: —it:' ^ 3 °f - 5 Official use only. Do not writ in this area, to be completed by city or Town of ci'1 City or Town: Permit/License #_- -: Issuing Authority (circle one): I. Board of Health 2. Building. Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other r Contact Person: Phone #: a SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: A _ ,, N /► /� Not Applicable ❑ Name of License Holder : J E V "14 om' �.`>r e. 2,,c. mit- cAs`Lc) License Number Lich, eViiszArriArnit ra.b , t F _ 51-7,-)11 Addre "� Expiration to A o (Y P/t3 e3 5Z- Signatur Telephone 9 :Reciiiatered:Ho►ne:improyement OritraGtorY,g...a1 - .... 4. ,.w , a :;3� �nuv � >. Not Applicable ❑ 141-"L N 7 Cc LL f r - 3'z L vim. Company Name Registration Number A S iM ' ix "I rift /v - kip islezrrid firFr,i, i i j i - 31t 0 Address yr Expir tion D to _ / W At Tele 4411 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 /Q No ❑ t4 0j .. P.ner ten on The_current_exemption for "homeowners ".w,.a_s 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 1083.5.1. 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 _ . _�T ----- loll `port ainptori ire martce, ae�rzl� - oat` .- ` :- . e• °v - + , , . e _ -- s- Gerreial.L- aawsAnnotated. - Homeowner Signature 3 - •r SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) PS Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [C] Siding [❑] Other [❑] Brief Description of Proposed Work: ?ha ri t icN e F 4 L 4tA ALA dZ.°? ci..c.,.,sCT %Y► iSnnGc= ,.&ticrazir=eri Alteration of existing bedroom X Yes No Adding new bedroom Yes )( No Attached Narrative Renovating unfinished basement Yes __No Plans Attached Roll - Sheet 6a..if'x hknite::andTiicadditiortto housinci,::coiiiptete the f©ilowirnq: 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 , NE Lt, f i /4c 4 i (-sH i? , as Owner of the subject property ^^��/� 1� hereby authorize � 4/vI L ::; VAN N✓t1 ? •— to t on my b half, in all matters relative to work authorized by this building permit application. • ` A c A Si ture of Owner Date 'Z'A,/ C, VAN. t J4 - rrel- , 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. } - 01" VA AL N`77 Pnn Na N Sign tur of /Agen /1/f1' c J 1 ate , 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 '. _ _ .. ._..__. L______.Y Setbacks Front Side L:..„......„__ R M..__ < L:_„_ ....... R::______: _ Rear Building Height Bldg. Square Footage r ----- F ---- `; % Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces M ....- ,---- - 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 0 YES IF YES: enter Book i , Page: i and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 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 0 IF YES, describe size, type and location: i "---- . -- D - A - re t ere any proposed chianges o or a itions o sig ns intended for`t1 e 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 StofPerfrt z 'Building Department Cuit Dttveway= : °`�` ,c U. '\ Main Street Se erlS Avaifa .Jwr- n ` � � G." Room 100 �Na"t Iuaila� ``� '� �� `g� �t F l `� C ampton MA 01060 C .�, i fe phone 413- 587 -1240 Fax 413- 587 -1272 PJ Sts Par s-= o : #0 a ., Ottie e 4' a 2 r ,� 3 . t x -� 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: '' nj.0 ' Na1t. c.J ..r Map Lot Unit Lvrz.�._i■it. LJ I✓ ' 1 Zo Overlay District Z Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: C.. C , 014. Name (Print) Current Mailing Address: X. V' ' Ci Telephone c Sign ite.4 re tilt/VI 6 2.2 Authorized Agent: q e,` ' ¼ % t4 L 0-�"r A I. D 3 pi ES KAN! r J 4 -r 4 U r Trr-I Pt &-LD f'A A i B ‘, c., Name (P ' t) Current Mailing Address: Signatur Telephone C SECT N 3 - ESTI ED ONST UCTION. COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of 5 Construction from (6) 3. Plumbing _ Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection B. Total (1 + 2 + 3 + 4 + 5) fc1, Check Number 10 i, �T - This Section For Use Only Date Building Permit Number Issued: Signature: Building-Commissioner/Inspector of Buildings - Date File # BP- 2010 -0260 APPLICANT /CONTACT PERSON JAMES VAN NATTA ADDRESS /PHONE 403 SOUTH MOUNTAIN RD NORTHFIELD (413) 498 -2698 PROPERTY LOCATION 68 NONOTUCK ST MAP 23D PARCEL 005 001 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 iO 9 9 #,C6' Fee Paid JQ Typeof Construction: CONSTRUCT LAUNDRY ROOM WITHIN EXISTING BEDROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 040620 3 sets of Plans / Plot Plan THE FOLLOWING 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 s 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. 4•1111•111MINI■ LT . � i \ o 4 ° tY 1I d -zad f'/' 'FS c 'Tg / t/Y 68 NONOTUCK ST BP- 2010 -0260 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23D - 005 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 -0260 Project # JS- 2010- 000335 Est. Cost: $6000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAMES VAN NATTA 040620 Lot Size(sq. ft.): 14069.88 Owner: OVERTREE CHRISTOPHER E & HEIDI Z HAGHIGHI Zoning: URB(100)/ Applicant: JAMES VAN NATTA AT: 68 NONOTUCK ST Applicant Address: Phone: Insurance: 403 SOUTH MOUNTAIN RD (413) 498 -2698 NORTHFIELDMA01360 ISSUED ON:9/17/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT LAUNDRY ROOM WITHIN EXISTING BEDROOM 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: t9 , ,,v� 4 Driveway House # Foundation: d �f Final: ( epa )41.0111Ci Final: Final: Val io4/ �� f y Rough Frame° kr / V 0- a _, /,�, Gas: Fire Department Fireplace /Chimney: -/G Rough: Oil: Insulation: Final: Smoke: Final: OK i ( THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. if i'E" ° �, t .--- -.- ' --* Certificate of Occupant 1- -- ----( S ignature: FeeType: Date Paid: Amount: Building 9/17/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo