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LOT 1 I ! ; 1 , I . 1 ; 1 1 1 t I V cA, rtx:Nret I I ■ si. -Pr. 1 _ Ti , 1 1 1 1 . , 1 1 1 1 1 1 , , / ; 1 , 1 ; 1 1 16 1 Y l 1 > - -- 80 —V- ' 1 1 ----,- ,P... f , 'CS 4 4, ,e47"„,--....- s.‘ • 1 i , 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, 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 d . • . r, The Commonwealth of Massachusetts =v-=f_---- Department of Industrial Acidents • , l ok —.-r=-- 1 t• -7:- ' Office of InvestigationS . 600 Washington Street Boston, MA 02111 - ---:-.., •,,, www.mass.gov/dia , • -,r, Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers , .. Applicant Information Please Print Legibly _ Name (Business/Organization/Individual) : e Mery , b-pyvie , - , -, ' . • ,. . . Address: LI 0 Oct k ■5 1-, City/State/Zip: 10et-exc< / 0 [ 062 Phone.#: Lii 3 —.5-es -7cPLtd>, - Are you an employer? Check the appropriatebox: • . Type of project (required): 11' 1.WI am a employer with 4, 0 I am a general contractor and I 6. 0 New construction . have hired the sub-contractors employees (full and/or arCtW listed on the:attached sheet 7. 0 Remodeling 2..0 I am a Sole proprietor or partner- These sub-contractors have ship nave no eiloyees 8. 0 Dernolifion working for me in any capacity. ertgloyeesand_liave workers' . 4.,... - -. • . •.- 9. 4111.1.1dini'didhii. [No- workers' comp. insurance 10.0 Electrical repairs or additions r., rec1 ' 5. 0 We are a connotation and its 3. LI I am a homeowner doing all work officers baVelxercised their . 11.0 Plumbing repairs or additions myself [No workers' corrp. right Of exemption per MGL r--7 12.11 Roof repairs . • insurance required.] t • . r. 152, §1(4); and we have no employees. [No workers' 13 ' c 0 Other , . ' comp. insurance reqtiired.l. . • . . *Any applicant that checks box 17-1: must also fill out the section Maw showing their woricers cot peasation policy iaformation. t Homeownera who submit this affidavit inificating they are doing all work and thea hire outside contraitors must submit anew affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether ornotthoseentities have eMployees. If the sub-contractors have exoployeca, they must provide their workers' comp. poficytimmber. . : *. .. - . ' . • . • lam an employer that &providing workers' compensation insurance for nay employees Below is the policy andjob site information. . Insurance Company Name: fl Ct../ - ‘ - `:- 1 " 1 leVS, Co. . .. ' • - . . - ‘, i'Ll C GAO/ ii.Y.•44 eYaor/ Policy # or Self-ini. Lic. #: -Csommglamageommiegia****Ka Expiration Date - * 5 /P /, ..? Job Site Address: 6. / '''c' \Si, 4-ee06 frkt; .. c- - - CX 0,5 Ay/State/Zip: • . - _ • Attach a copy of the workers' compensation policy declaration page (showing the policy number and date). . ..... ..._ ......... . , • , Failure to secure coverage as reqUired Via& Seetiont25A 152 can lead to the iiiinesitiini Of - third - nil penalties of a fine up to S1,500.00 and/or one-year imprisonment; as well as civil penalties in the form of a STOP WOWS-ORDER. ancla fine of up tanso.00 a day against the violator Be advised 'that a copy of this statement may be forwarded to the. diffeeof , InVestiiiiiiiiis &the insurance Coverane verification. . _ . .. ..... --„:........ :-.....-.... Idom herebysertift under di , . - an ,• , tsities ofperjray that the infornurtionprovidedsibovez&tnie_andiarn ' ■-1----"Wi"...----s!.....--- .....,_ . _.._... . Siu■ tare ........G__-_.■.' • • - - -:- 7 :' ' -- ate- S gct / 2 Phone ii: -11 3 -- ,s - sf'sc , " (PL-16P1_ : •.._ - ' • - .. . - Official use only Do not write in this area, to be completed by city or towd'official. City or Town Permit/License # : . Issuing Authority (circle one): .- • .1. o Bo th ar er d of Health . 2. Building Department 3. City/Town Clerk 4. ElectricalItispector 5. Plumbing Inspector / 6 Contact Person: Phone #: • 1 a. SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: _ Not Applicable 1:1 Name of License Holder : 3(S S �!r � C� 0 -77 L i , f' License Number ( -4 k S.-F-. i vz I ' / a Address Expiration Date k e4 (9/06.a V. Signature /' Telephone 4- 113 — ,5cS-8`IJ2 49 R Not Applicable ❑ ':� , ,:�- oiiaealindrovmeni�ita # ���� � � .,., -� � .� ��.�:�:� M�w .--e55 ./'"l (in tGSeriC" / 3`i a Company Name Registration Number 0 Oc /Ott q /1 al Address Expiration ate — 1' Ore �C . (1 (2 Telephone 5 / 0 SECTION 10- WORKERS' COMPENSATION. INSURANCE AFFIDAVIT (M.G.I-. 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 ❑ 1 M it nt .O eM eial I 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 Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature t SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition Et Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors El Accessory Bldg. El Demolition ❑ New Signs [0] Decks [El Siding [D] Other [0] Brief Des ription of Proposed , , Work: c m ye. A 6 rvt:rcl cA r-∎ Yjs,', 1 ca_ /0 X le s,-' rr� •+--' Stria -1) Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a If NeW.1 0 IS 'B1id:=tfC aiddi ftyl.to, iistllla it s iiiNairlPLete he foitainlia: a. Use of building : One Family / Two Family Other b. Number of rooms in each family unit: . Number of Bathrooms 2 c. Is there a garage attached? ND d. Proposed Square footage of new construction. /d Si. iChDimensions /0 .( 18 e. Number of stories? .2 f. Method of heating? ' Fireplaces or Woodstoves "' Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction W I 1- i. Is construction within 100 ft. of wetlands? Yes 1 4ro . . 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? V Yes No . I. Septic Tank City Sewer V Private well City water Supply ✓ SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, MAff EI(fK Die , as Owner of the subject property hereby authorize JeSS e i l(M ON-el a on my behalf, • II matters relative to wo uthorized by this building permit application. 14 j . e ,;,,,,,d 5/A-7 //a Signature o ner Date l4 /WE1 /EN 1)i ))/ J e5�, � 5dt'1 �'"7 , as Owner /Authorized Agent hereby declare that the stateme s 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. u L AI I tt IC. A A rt Tc 55t / Vt1C"7 rint Name /' i ii. I �.,� /� Z - Signature S 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' illed in by Building Department Lot Size f € � Frontage L >7' I (f Setbacks Front L & i f I € Side R : 1 - ‘ 2 3 - 1 01 L: gi_ R: /31 b 1 1 1 Rear i 7.� i T - Building Height i Bldg. Square Footage r7 '°„ r' ; j Fr' r Open Space Footage y (Lot area minus bldg & paved [ J Pi ` ' ‘'i ra 1 I parking) # of Parking Spaces Fill: � _ (volume & Location) i U_ , i A. Has a Sp al Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES 0 IF YES, date issued:! 1 n , IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW Q YES 0 IF YES: enter Book € Pag and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 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 e r 1 . IF YES, describe size, type and location: _.____......._,.. D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, exca ion, 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. l ..:, _... _ _------1 q v ° ett ° .ia; e 'k � « ¢as ' City of Northampton a ; � APR — 3 ZO�Z Building Department . m v 4 : - 212 Main Street _ . g . Room 100 . u BUILDING Nu► E orthampton, MA 01060 4 4 . , r .- .-- ---- -- ON O1 3f - 587 -1240 Fax 413- 587 -1272 m $ �'.. �' � 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 L, �� f r\�, n Map Lot Unit "c e & S I"�;/1 . fl t 'J .S S Zone Overlay, District L Elm St. District CB District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: r� /� / Nk[.� '+� V 1En -��r,d C t.4e -ice r JI Name •rint Leeds t14 D/G'S i Current Mailing Address: �I . r _ ' =' Tel Signature / ` L 1 3 5 �i S 0 f' p 6 cp 2.2 Authorized Anent: S M �- cx e (A c ©c. K. S I-. Name (Print) Current Mailing Address: 'F � C Telephone Sig - ..f SECTION 3 - ESTIM CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building () (a) Building Permit Fee 2. Electrical (b) Estimated Totst of i O Construction from (6) 3. Plumbing / Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection a /' 6. Total = (1 + 2 + 3 + 4 + 5) j 090 Check Number Q 2 93 j /ci v J f This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 37 g 7573 zpott 6 '‘' , File # BP- 2012 -0862 etA4 kr-Qicu'' APPLICANT /CONTACT PERSON JESSE MONTGOMERY ADDRESS /PHONE 40 OAK ST FLOREN CE (413) 585 -8482 PROPERTY LOCATION 6 HEFFERNAN ST MAP 11C PARCEL 006 001 ZONE URA(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Ag 9 pi V Fee Paid iJ [J Tvpeof Construction: REMOVE 8 X 6 MUDROOM & CONSTRUCT 10 X 18 SUNROOM r New Construction Li AC‘ Non Structural interior renovations A- v ikt O Addition to Existing IMMIN,FiW i C Accessory Structure .,' W ''' Building Plans Included: Owner/ Statement or License 077410 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF�'RMATION 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 lit e n Delay O de / .,A V m ding O icial 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. 6 HEFFERNAN ST BP- 2012 -0862 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 11C - 006 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ADDITION BUILDING PERMIT Permit # BP-2012-0862 Project # JS- 2012- 001516 Est. Cost: $25000.00 Fee: $150.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JESSE MONTGOMERY 077410 Lot Size(sq. ft.): 8189.28 Owner: POLLARD MARY ELLEN Zoning: URA(100)/ Applicant: JESSE MONTGOMERY AT: 6 HEFFERNAN ST Applicant Address: Phone: Insurance: 40 OAK ST (413) 585 -8482 FLOREN CEMA01062 ISSUED ON :4/12/2012 0 :00 :00 TO PERFORM THE FOLLOWING WORK: REMOVE 8 X 6 MUDROOM & CONSTRUCT 10 X 18 SUNROOM - SUNROOM EXEMPTION REQUIRED 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 4/12/2012 0:00:00 $150.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner