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23D-025 ¢St1AMP� - • • ,� ti$ L2h t7 of ~Qrtham ±nn �L _ Z e J 44 Y p 01 ass a cipis efts I^i - - - ~ t— 1 DEPARTMENT OF BUILDING INSPECTIONS —_ �Z G 0 INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sup';_ . 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 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 any 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 ins- ection if res wired and a final build 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 me. Date Address of work location "\ The Commonwealth of Massachusetts Department of Industrial Accidents 4 b Office of Investigations _ d 600 Washington Street —..:— Boston, MA 02111 °'4 ' WWW.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders / Contractors /Electricians/PIumbers Applicant Information Piease Print Legibly Name ( Business /Organization/Individual): Q� y\� (1J1C'� (?j'r (C Address: / L .- C kt k i -Clot; t (A City /State /Zip: /�ney ,�- Mk Phone #: 1 i/3 36 t" 7 L. � - j Are an employer? Check the appropriate box: Type of project (required): I. I am a employer with 1 4. [] I am a general contractor and I employees (full and/or part-time).* have hired the sub- contractors 6. ❑New construction Iisted on the attached sheet. 7. /14 Remodeling 2. [1] I am a sole proprietor or partner- ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. We are a corporation and its [No workers' comp. insurance required.] employees and have workers' 9. ❑ Building addition comp. insurance.: 5. [] 10.❑ Electrical repairs or additions officers have exercised ter 11. Plumbing repairs or additions 3. [1] I am a homeowner doing all work h id hi ❑ myself. [No workers' comp. right of exemption per MGL c. 152, §1(4), and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13.E Other comp. insurance required.] - -- - *Any applicant that checks box #1 must also till 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. *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: (2,0( y1 i L .Sj k T{-iSt.i ra ,- - e-O Policy # or Self-ins. Lic. #: we.. - 067d- ) ®7.5 3 Expiration Date: 9 - 30 ' / Job Site Address: iijW 6- 1 yh b City /State /Zip: VC/ 1 ical1 A4 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 up to $250.00 a day ag.;6 „. e violator. l Be raQe verification. ied tha copy of this statement may be forwarded to the Office of Investications of the 1 l- I do hereby cert , , , 1 f 4 d penalties of perjury that the information provided above is true and correct if /f Signature: Date: 191/ % ` l / Phone #: 1 / 1 / i e; 7 ;) z72 li Officiai use oniy. Do not write in this area, to be completed by city or town officiaL City or Town: Pernut/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 Sup isor: / Not Applicable ❑ Name of License Holder : r � C\ruct‘ License Number t i (JIM S4 0/0,4 440 niCtrid .1 • Address Expiration Date Signat : Tr. Telephone / 1./0 -/ / S 5 - 3 9 Re gTstetedtlameJr riprovemenlnCoritfractor ` _ , µ ; y - Not Applicable ❑ /5, Company Name Registration Number Address / /� / l 'p 1 Expiration Date 7 4 Chi's /G7 1 x'1/ /1 4-Telephone 7 /> %J:fl/.)9 7 /4� zoic)_ SECTION 10- WORKERS' COMPENSATION INSURANCEAFFIDAVIT (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 ' Na ❑ y y; 1 Home Owneri Exemp ion 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, von 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 [J Replacement Windows Alteration(s) et Roofing i ! Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Ei Siding [El] Other [ I] Brief Description of Proposed / �IJ_ 1 y + J [ f s ( � Work: jtj l-a. L A b i Fu g\ S I ,ivt)cL 1 Il'k e '(''CO C IAA l / 1 TL.r '1 IMO 4c - ca.4 ['l Alteration of existing bedroom Yes X No - Adding newbedroom Yes ___ No Attached Narrative Renovating unfinished basement Yes ,( No Plans Attached Roll - Sheet / 6a If -New house anc! or addition to' exis housing „ complete the a. Use of building . One Family Two Family Other % V� 4 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 lo. s cons ruc ion wi - 1 • • • . ' • • • • -' 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, / / '�,,T: // ,�A O�1.t�AY % l�G f � ' , as Owner of the subject ProPe - VI % hereby authorize 23Ub aeer ( if Lc� � y -� fu& !. u” a to act on my behalf, : n all rt� Afters relative to work orized by this building permit application. i f / Si a tur e of O r Date I, 7 6 , 1-- ( nS 4 am: 41 Crl Co - , as Owner/Authorized Agent he by declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signe• under the pains and pen It s of perjury. I 1.' pen f Print Name /1 /// ( / Signature . Date 4 4 I , Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Infor . ion ‘m Existing Pro osed Re uired b Zon • : / e '" v P q Y +� se, y Y, • This column to be fil .• in bit:, St ,•v > �'• Building Department ' Lot Size —... ._ — ` ' .' Frontage Setbacks Front • Side L: R:, L - R: Rear • ' Building Height Bldg. Square Footage % Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: 1 7 F (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? - -NO - : e al i -- — IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO r,,(+ DONT KNOW 0 YES 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 ® NO M IF YES, describe size, type and location: D. Are there any ro osed changes to or additions of sins intended for the property ? YES Q NO I 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 , ��� IF YES, then a Northampton Storm Water Management Permit from the DPW is required. Depar€rnent case Q • � ��© City of Northampton Staftts fPe Building Department CsrbCr i.t er t ;- - `��� :� • � 21 M ain Street Seer�eptreA�ai'fa€nl►t� � � `�� ; ��� �� R oom 100 1tafer. AVa stabtltty , :' 'Northam ER MA 01060 T><ro Se ofSU a n , , o ne 413 - 58 -1 STUC 240 Fax 413 - 587 -1272 PIoFlSEfe Pla ��. QtherSpeb - PLICATION TO CONRT, ALT, REPA RE OR DEMOLISH A O N E O R TWO FAMILY DW E LLING SECTION 1 -SITE INFORMATION This section t o be comp leted byoff<ce 1.1 Property Address: Jam, 1 f Ma .. Lot Utitt Z ones OVerhay Dtst E frrt~sf-Dts trict . CB•District - SECTION 2 - PROPERTY' OWNERSHIP /AUTHORIZED- AGENT 2.1 Owner of Record: A� 1�� Elm — ��Q ,W Name t) / J , - ' Current Ma Address: . ' I 4 i ci . gnature !,.,, - � j/ Telephone i i 2.2 Au •r'zed A•e t: ,r�p�� Na e (Tint) / C urrent Mailing A i s l3 33 1 a�f,2r Signatur/ •f /, �/ �� Telephone r SECTION 3 - ESTIM COSTS Item Estimated (Dollars) to be Official Use Only completed by Cost p ermit applican 1. Building (a } Permit Fee 2. Electrical (b }Estimated Total Cost of /5 � Construction_from (6) 3. Plumbin Building Permit Fee c 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) Chc%aI eck se N um be r This Se F Offi U Only , - - ' Date Building Permit Num Signature: ber. Issued: I Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0682 APPLICANT /CONTACT PERSON ROBERT OBEAR ADDRESS /PHONE 47 W CHESTNUT HILL RD MONTAGUE (413) 367 -2424 0 PROPERTY LOCATION 488 ELM ST MAP 23D PARCEL 025 001 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 v � Fee Paid 7 Tvpeof Construction: MOVE INTERIOR WALL TO CONVERT CLOSET TO 1/2 BATH, NEW KITCHEN CABINETS New Construction Non Structural interior renovations Addition to Existing_ Accessory Structure Building Plans Included: Owner/ Statement or License 086260 3 sets of Plans / Plot Plan THE FO OWING 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 D - 'r /(/ S • . •. e of Builds •_ •' iv :1 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. c,",e- ,) F i itf tit/ TA Ao 488 ELM ST BP- 2011 -0682 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23D - 025 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: WIRING FOR RENOVATION BUILDING PERMIT Permit# BP- 2011 -0682 Proiect# JS- 2011 - 001119 Est. Cost: $9000.00 Fee: $55.00 PERMISSIO, N IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ROBERT OBEAR 086260 Lot Size(sq. ft.): 8015.04 Owner: FOGEL ASHLEY Zoning: URB(100)/ Applicant: ROBERT OBEAR AT: 488 ELM ST Applicant Address: Phone: Insurance: 47 W CHESTNUT HILL RD (413) 367 -2424 () MONTAGUEMA01351 ISSUED ON:2/24/2011 0:00:00 TO PERFORM THE FOLLOWING WORK: MOVE INTERIOR WALL TO CONVERT CLOSET TO 1/2 BATH, NEW KITCHEN CABINETS POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: V Footings: Rough: r" °)( Rough: House # Foundation: Driveway Final: Final: 3 " 3-3 'ji Ole—Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: OR '? "� 1 i Gn 14--- 5 4 Final: Smoke: Final: 01.< ..g (( C/V 4, THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND RE9 t' , S. 7 Certificate of Occupancy(,,, pF -'a.r c.�,. YL QV�c L e Si gnature: FeeType: Date Paid: Amount: Building 2/24/2011 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck – Building Commissioner