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29-491 City of Northampton Massachusetts 4 DEPARTMENT OF BUILDING INSPECTIONS r : w , 212 Main Street • Municipal Building � L , ' "e Northampton, MA 01060 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 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 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, ; CJ � - - understand the above. ( H o A , Gy . me owner resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date 4f//L 1 - Address of work location y6 2 12yA/ /'/, • 03/27/2012 13:58 FAX 4135871094 NORTHAMPTON WWTP a007 o �. • , v i p o of I- ePtil -6 1 VdV r 7-L 1101/g a 1 3N,a'po r! adff boy' 1 1 5_17P I s S 900121 asp NO BOK t6OTL83CT1 Slid CO =PT ZTOZ /LZ /CO 03/27/2012 13:58 FAX 4135871094 NORTHAMPTON WWTP Loos r.. %A v.`. 03/27/2012 14:03 FAX 4135371084 NORTHAMPTON WWI? ( t 007 Focht •.. diT 60 C y 1 :1 cs 41 'o 03/27/2012 13:57 FAX 4135871094 NORTHAMPTON WWI? 411005 t.t 'Ts tit "f. . • • 03/27/2012 14:03 FAX 4135871094 NORTHAMPTON WWTP fij 006 The Commonwealth afMassachusetts ,, ` k_ . Department oflndustrial Accidents "M �= = r Office oftnvestfgatio►rs 1/4416.. :. r yYashington Street Bositon,111A 021).1 _ ' www.mass.gonl/die Workers' Compensation insurance Affidavit: Builders/ Contr actors/Electricians/Plnmbera ,AnDlicant information Please Print f..esgibly Name( 'vidual): V►a11M Ml''?EIe Address: /7 ..... Iv ,e .. . .. — City /State/Zip: `L e E Ir MCI o/D'G 2., loon #: s-, ''1-rd-r9 Are you 9n employer? Check the appropriate box: Type of project (required): 1.0 i am a employer with 4. ❑ I am a general contractor and I 6. L mew construction employees (full and/or part-time).* have hired the sub - contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet: t 7. 0 Remodeling ship and have no employees These sub - contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. 0 Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its olequired.] officers have exercised their 10.0 Electrical repairs or additions 1 3. Le I am a homeowner doing all work right of exemption per Mt3L 11.0 Plumbing repairs or additions 1 myself. [No workers' comp. c. 152, §1(4), and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] I3.❑ Other •Any applicant that checks bat ill must also till out the section below showing their workers' compensative policy information. t Homeowners who submit this affidavit indicating they arc doing Ail work and than him outside contactors must submit a now affidavit indicating arch. ;Contractors that check this box must attached an additional sheet slurring tdc name of the sub-contractors and Their workers' comp. policy information. I am :providing an employer that k workers' c Insurance for my employees Below is the policy acrd, fob site information. Insurance Company Name: –.— _ - Policy # or Self -ins. Lic. #: Expiration Date: . - Job Site Address:_ City/State/Zip: Attach a copy of the workers' compensadon policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one -year impriaomnent, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the viola. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for Insurance coverage verification. • 1 do kph* .1' under its pains a nd penalties ofperfury that f' he lip arr ►ion provided above is true and comet --- Signature: el a .1 ` 4.rce. - Date: 21 Alice ! se Phone #: .. _ -- . I Official use only. Do not write in this area, to be completed by city or town official, i City or Town: , _ Permit/l.,icense # __ .. _ _ _ _ Issuing Authority (circle one): I 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 03/27/2012 13:57 FAX 4135871094 NORTHAMPTON WWTP 1004 . . v. 03/27/2012 14:02 FAX 4135871094 NORTHAMPTON WWTP [i1005 SECTION 8 - CONSTRUCTION SERVICE$ 8.1 peened Construction Supervisor: Not Applicable CI Name of License Holder Linens* Number Addre& v _ Expiation Date Signature Telephone 8: Rest�tered.hiorttes tDt+oveme►1t Contiaact3dC ;• , , . .. ' .. Not Applicable ❑ ddlISM nv Name Registration Number Address -- Expiration Date Telephone SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this davit wiif result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes. 0 No. 0 11. oioae C .ne r ac�i tut on[ The current exemption fbr "homeowners" was extended to include fir oeeostie,d ly__0_ng 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 tbat the owner acts ss auneryiwr. C1Mr Sec�ia►198 W Ronteowner: 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 struc:iures accessory to such use and/ or farm structures. A oerson who co tracts more than one home ioA two -nar period shall not be cjaideredgpo weer. Such "homeowner" shall submit to the Building Official, on a form amble to the Building Official, that betake shall be responsible for all such work aerfarwed under the build* permit, As acting CIMMDICAMLNEnnlifdtr your presence on the Job site will be required nom time to time, during and upon completion of the work for which this permit is issued. Also be advised that wlth reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability ofEmployers to Employees fbr injarirss not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for persons) 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 , 03/27/2012 13:57 FAX 4135871094 NORTHAMPTON RIPTP Z003 03/27/2012 14 :02 FAX 4135871094 NORTHAMPTON WWTP 411004 SECTION 5- DEfiCREPTION OF PROPOSED WORK(chack all applicable) New House jJ Addition 0 Replacement Windows Alteration(s) 0 Roofing Q ,-,�(� Or Doors Accessory Bldg. L.�'J Demoltttan ❑ New Signs MX Decks [CI Siding 0:II Other [C1 Brief Description of proposed /)( 3 0 Work: CONr T' PCT - /GA/ r�� �,a G A /eh Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached toll - Sheet aa; it New ho . :...... ut�Q..atid`or`actditioii iii:ixisti'Eia : tioewlna iiiimalete:;foliowlriq - 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 constriction_ __ 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. WM building conform to the Building and Zoning regulations? Yes No . 1 Septic Tank City Sewer .r-- Private well City water Supply SECTION 7a - 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. nahne of Owner Date - �— I, — _ i t / / r elm L AMA go-, . 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 at perjury. IA/ / L 1 '-»m 4-A►- 1.1#P Part Name G... .,, . 13 ,1i 9 Y' / A Signature of OwnerlAgent Date 03/27/2012 14:02 FAX 4135871094 NORTHAMPTON WWTP 411003 Section 4. ZONING AU Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zing This column tu be filled in by Building Department • Lot Si '4 /Idl 1" ---------------- 1 i -IMMEMI I Frontage L___ Setbacks Front L E1 i Side L:1-----.1 R:t . . --1 1.,:al R:1 J 1 ---- 1 Ent 1 11 1...........i Building Height = . tiii2,1 Bldg. Square Footage L___J L__J 14 1 1 L171 -- L....ii Open Space Footage Lot area minus bldg & paved .1 -....- ‘ ... 1 1 r{ C ---- 1 1 ---- 1 L(55 1 ' I • i , . n ‘ 0 ofParkin: S , aces r ---] Fill: 1 (volume & L. 1'1 1 _... A. Has a Specjat Perrnit/Variance/Finding ever been issued for/on the site? .---- NO DONT KNOW 0 YES IF YES, date issued:I J IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 1 YES 0 IF YES: enter Book I i Pagel_ :1 and/or Docent ft _......._ B. Does the site contain a brook, body of water or wettands? NO er 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 0 , Date Issued: 1 ,.. t ______ ... _ ........ --di. C. Do any signs exist on the property? YES 0 NO er IF YES, describe size, type and location: L 1 ....._ ... .... _ ......... . ,... D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO 0 IF YES, describe size, type and location: I __......._.............,........._____ .......... E. MI the construction activity disturb (deering, EPEdin9glation or filling) over 1 acre or is it pert of a common plan that will disturb over 1 acre? YES 0 N IF YES. then a Northampton Storm Water Management Permit from the DPW Is rewind 03/27/2012 13:58 FAX 4135871094 NORTHAMPTON WWTP Q001 03/27/2012 14 :01 FAX 4135871094 NORTHAMPTON WWTP 11002 CE1VED G Ity of Northampton Building Department //•(u� : R `n e P �. f VU• �•.C'I{�v..[f ��.RY7 ,"• ":'�...'y :. �;::^S• ..:..ai'�.:t(�fi +.:fi.•JY: mi 2 7 201a 212 Main Street 3tYte}iir ?Avdilatiity ' _,,� E > F' . Room 100 .��N!7,'r '.' " •` viva -. :t ^' +. orthampton, MA 01080 sets ? atsiwcrur► €F'li�ris -"' :;a •;.� °; ^,:i;a T. OF BUILDING _ DEPT. e 8 7 -1240 4 i58 t?lot�8`iteieiis :'<-" z.: VLT1 `' ..�,Y.+ :::'st.:; ^`'.�:o: <::•.•::� I APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1- SITE IPFORMATION 1.1 Property Address: Thie section to be cowl/eked b j 11 40? e y hiv re D Map Lot FL O NG ` Zone owriar Distnc# Elm St DIsMcR CB District ' SECTION 2 - PROPERTY OWNERSHIP /AUTHORED AGENT 2.i Owner of Record: WILLIAM L I4 t1 & ee Yd" 9 it i N /2,i7 Pfd 'ANL°E Name (Prird Current Mailing Address: trig- , P 1T, - Telephone signature 2.2 Authorized Arrant: Narne (Print) Current Marling Address: Signature Telephone — — SECTION 3 - ESTIMATED CONSTRUCTION COSTS 1 item Estimated Cast (Dollars) to be I Official Use Only completed by permit applicant r-- 1 Buiding p 19J &A7/ON r q (a) Building Permit Fee + 2. Electrical tom) ir.sermiked RAS Cedtdi Construction from 13) 3. Plumbing Bunclin9 Permit Fee 4. Mechanical (IIVAC) #i. Fire Protection $10 �� 6. Total (1 + 2 '+' 3 + 4 + 5) Check Number This Secti n F Onl�r - m tt% Budding Permit Number. I Issued: Signature: _2L� Sul4ng Commissioner/Inspector of Buildings -- - pate iose 457 RYAN RD BP- 2012 -0875 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 491 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: FOUNDATION BUILDING PERMIT Permit # BP- 2012 -0875 Project # JS- 2012- 001535 Est. Cost: $5929.00 Fee: $108.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 19994.04 Owner: LAMERE WILLIAM C & PATRICIA A Zoning: Applicant: LAMERE WILLIAM C & PATRICIA A AT: 457 RYAN RD Applicant Address: Phone: Insurance: 457 RYAN RD (413)584 -15890 FLORENCEMA01062 ISSUED ON:4/9/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: FOUNDATION ONLY FOR 18 X 30 GARAGE 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: FeeType: Date Paid: Amount: Building 4/9/2012 0:00:00 $108.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner