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24B-060 (3) ......— ... - ....,_ „. \... J- ...., . . ... .. , ....-- ,..--. ‘ --- ...-- I ( , e ( o 1 i. '....-.,. t j'4 ke ■ 4 S.* . (.......................... ,...,, ,fro ■ A ....ne , . 1 . 1 I , -?.. , t '"'" ........*„...... 11+ r* I' .............,› . cr. , IN V _ „,, — — , ,,,, ,_ „ , ....— . . .. ■ :v \ N.vi e ro N \ -......0 4 1) \ • . 1 . , ) 14; ' 11f41114':*4 . , 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 Theinspectio pro 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-conj unction... to_ thebuildingpermitissued ,_ and_that they get their required inspections. Failure of the individual trades to secure the permits and inspections as required can DELAY the .roject until such time as the proper permits and inspections are made I A understand the above. II 111 I I • (Home own resident's signa ure requesting exemption) I will call to sche• le all required building inspections necessary for the building permit issued to m . Address of work s,1 location ��� f a. ('1 ( 7) f\ U lC. - J The Commonwealth of Massachusetts Department of Industrial Accidents I =. - it Office of Investigations • .; 0 600 Washington Street Boston, MA 02111 �„ mi.,� . www.mass gov /dia -Workers' Compensation Insurance Affidavit Builders / Contractors /Electricians/Plumbers Applicant Information Please Print Lecribly Name ( Business /Organization/Individual): C""2 ( ©r y L .. e. r S \ et e. r Addres y ro . r A, S ' - City /State /Zip:13o t C o A . A + d , n I H o . , Phone. #: ' 1 3 5 ?5 -9 (( 2(0 Are you an employer? Check the ap box: Type of project (required): i' 1. ❑ I am a employer with 4. fl I am a general contractor and I employees (full and/or part - time).* have hired the sub- contractors 6. [] New construction 2_ ❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling ship 2MA have . no employees These sub- contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' Y P ty 9. 0 Bufidi g addition [No workers' comp. insurance C4mP. insurance.# e ed 5. 0 We are a corporation and its 10.0 Electrical repairs or additions o ec_have xercised_thcir_ �I_ m repairs or additions 3. I am alaemeowner -doing ll �verk — l h g eP myself [No workers' comp. right of exemption per MGL c. 152, §1(4), and we have no 12.0 Roof repairs insurance required) 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_ $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: 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 $1,500.00 and/or one -year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a ftne of up to $250.00 a day against the violator. 13e advised that a copy of this statement may forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ' under the pain ; and , _ fillies ', pe ' that the information provided_above true .dnd_correc . -_ -- _- Si. .. ture: �� _' I AL / L � � � � . I _ Phone #: ( ( 1 3 1 5'4 S - 7- Y 2 6 - Official use only. Do na Willi in this areiz, to be completed by city or town Merit 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 #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : _ License Number Address Expiration Date Signature Telephone 9..Regisere'd:.Home' MPfcvement`Contractor` ,. b Aa . ; ' Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone 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 ❑ 11 ". wne p n The_ current_ exemption for "homeowners ".wvas 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 referenceto 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 rcspo ibility for co pliance with the State Building Code, City of o arripton rr. trance ; - . r • ;ri sOeneral Laws - Annotated. Homeowner Signature � � L _ L . , �! � _______ ti SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House Addition ❑ Replacement Windows Alteration(s) D Roofing ©' ,-� ( Or Doors 0 Accessory Bldg. E Demolition ❑ New Signs [D] Decks [Q Siding [De Other [D] Brief Work Description of Proposed 2 I a cq 1 shit ] / )(/ w Alteration of existing bedroom Yes No Adding new bedroom Yes / No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa if. kew:. house 'and aif housinci,; 'Oomp(efe thevfo#low ncE 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 , 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 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. c&Iff. Sign' e of Owner /Agent Dat: e. , 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 2.2 aCti. ._.. Sam Lot Size ._. Frontage _ - Setbacks Front p? � _.. R:.. 1=-: Side L.:_ L: <_tfr ' R:.i..~p'° Rear _ i s„j L./3j Building Height T" Bldg. Square Footage _° L _ % 1 Q! 1 43 \ Open Space Footage % _ (Lot area minus bldg & paved 4�= t� .r7 parking) # of Parking Spaces ti " °•" Fill: �/ , (volume & Location) _ A. Has a Special Permit /Variance /Findin ever been issued for /on the site? NO 0 DONT KNOW YES IF YES, date issued: IF YES: Was the permit r at the Registry of Deeds? NO 0 DONT KNOW ( YES 0 IF YES: enter Book Page? and /or Document #: B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES l IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained (C) Obtained ,Date Issued: C. Do any signs exist on the property? YES 0 NO g IF YES, describe size, type and location: iv -- -` ti. rd e there any 13T6posed'c tinges to or a ItlorlS of suns intended oar tre property ? YES Q NO e 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 a IF YES, then a Northampton Storm Water Management Permit from the DPW is required. • , r CC \ k � �t�.� 4 ,& -% 1 % `� „ C it y o f N St;#uslaf-PC W t 1 a R � � %" - , Building Department - r �k �, C - c,,,,,_,,,,, _- �� Q 4'' + �" , "- ,3e n 212 Main Street searu tis4ttcAAaiia itityi, � 4 10 Om 100 `xk G 1 Nor tha mpton, MA 01060 Tw o s ; " � �� I � � phon 413;87 40 Fax 413- 587 -1272 4 an tm s ',.. / �"' ( ,.a; - s ad w ��" C n,�. 4 4 t. e ' \ APPIiiCATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Pro er Address: This section to be completed by office 9 (a f. � ! Map Lot Unit Zone Overlay District ;Elm St District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Q 1_ cor e r / l -- G,--k Sfe 4 7 Name (•ri Currertag Addr ss: ill L..., am" _ _ e l l ..._.4 / rtir..� Telephone Signature 2.2 Authorized gent: G f e � L. Kt r ii -- "1" Hto g ra d T8 5{ •4c' Name P n — m m. ■+�... Current Mailing Address: `!,..•. , _.. COIr , - .n/(i" 875s - C t KZ(0 Signature I Telephone SECTION 3 - E TIMA D COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building $11600 (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 55 . Fire Protection . Total = (1 + 2 + 3 + 4 + 5) J� C7Q 0 Check Number "� This Section For . . Id Use Only`' . _ Building Permit Number. IIsssued: Signature: Building Commissioner /Inspector of Buildings• - . Date r , File # BP- 2010 -0184 APPLICANT /CONTACT PERSON KERSTETTER GREGORY L ADDRESS/PHONE 46 BRADFORD ST NORTHAMPTON (413) 585 -9426 () PROPERTY LOCATION 46 BRADFORD ST MAP 24B PARCEL 060 001 ZONE GI(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 14 'f 1 Fee Paid ?e f> Typeof Construction: CONSTRUCT 10 X14 SHED New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INI 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 Demolition Delay 2s , 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. BP- 2010 -0184 GIS #: COMMONWEALTH OF MASSACHUSETTS to -ow 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 -0184 Project # JS- 2010 - 000228 Est. Cost: $1000.00 Fee: $28.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 9496.08 Owner: KERSTETTER GREGORY L Zoning: GI(100)/ Applicant: KERSTETTER GREGORY L AT: 46 BRADFORD ST Applicant Address: Phone: Insurance: 46 BRADFORD ST (413) 585 -9426 0 NORTHAMPTONMAO1060 ISSUED ON:8/21/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT 10 X14 SHED 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 8/21/2009 0:00:00 $28.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo