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24D-058
• 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 ball 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 constructmn 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 backlit!), sonotube holes (before pour), a rough building inspection (before work is concealed). insulation inspection (ifreauired) and a final building inspection. The building department requires these inspections before the work is concealed, fail ure to secure these inspections can result in failure to obtain a certificate of occunancv 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 jermits 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 • 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 tome. • Date Address of work location • . The Commonwealth of Massachusetts ° Department o, f Industrial Accidents nk �• = l t • Office of lnvestzgatzons • + ' 6 600 Washington Street e. =:!..-: F - ' — Boston, MA 02111 j,�= - , www.mass gov /din -Workers' Compensation Insurance Affidavit .Builders/ Contractors /Electricians/Plumbers Applicant Information A, Please Print Lei'bly Name (Bus neseorgamiation /Individual): /-?/ Tit:4c - L- co s -Address: / cj.5 C-g i AO - . . A . p/073 f City /State/Zip: 5DUT))14, -1'7x) - Phone. #: 9) 3 S2(704., t / 04 - Are you an employer ? .Check the appropriate boz: - . -Type O f project (require: / 1.0 I am a Ya Io with - 4. [J I am a general contractor and I 6. 0 New 6construction hired the soli- contractors - ....layees (fall and/or part - time). 2_ �� I am a sole proprietor or partner- listed on the attached sheet 7. 0. Remodeling ship ate. have no a loyees These sub - contractors have .8. 0 Den Oht On . working for me in any capacity. employer anitbave workers' workers' comp. _ . octraP. ;ns n r L .. .- - - -- mg li on j S. 0 We air a on and its 10.0 Eleclncal repairs or additions 3. 0 I am a homeownta doing ill work hav work rereised their . 11.0 Plumbing repairs or additions exemption ti myself [No workers' co mp. on Per MGL 12.0 onofrepairs - instrance requiredJ t • .. 152, §1(4), and we have no • . etriployees: [No workers' • 13.i] Odher • pomp. iositrance reqUiced.j. : . 'Any applicant that checks box #1 must also fill out the section bdowshowmg wodi rs' conztian policy w€eaasrticn. . - t fioamwuers who submit this amdavit:iadratiag they are dolman work and then hire outside contractors must submit a new affidavit indicating such. Iccuttractars that check this box must attached an adirtiaoal sheet showing the name of the sub cantsactots add state wlsetherornodose entities have • employees. If the sub - contractors have en'rployees, they must provide their ' comp- polidy number. • . - Ism an employer that uproviding workers' compensation insurance for lay einplgyees Below is thepolicy andjobskte information. Insurance Company Name :. - • Policy # or Self-ins. Lic. # Expiration Date: .Job Site Address: City/Stafe/Ztp • . - • Attach a copy of the workers compensation_ p decla page (sh the policy number and ex 1 date). Failure to secure coverage;as required under Seatron '25A`6f1VIGL c: 152 call lead lo the iiiiii6siiiiili of c penalties of a fine up to 51, 500.00 and/or one -year iaprisonme as well as civil . penalties ia, the fos pia STOP W® -QRDER and a fine of up to 52 . 50_00 a day against the violator Be advised that a copyof thus statement maybe forwarded to the Ofie of ._ , Inv- • . ofthe DlA for insuurance co wt e atan: T I'do hereby under pa usi andpenalties of_perpay thafthe in, formationpro - vp b a r" ar; sianattire: . - Irate: 7 ) b • , • Phone #: v13 . 51-7 06 T .. - Official use only. Do not write in this area tir be completed by chy or to; i q daL City or Town: # ' . • 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 Supervisor. Not Applicable ❑ Name of License Holder : Dk CT 10 ` License Number / 't- AUO.9 11 i212r0?D Address Expiration Date so vT 4 i r Tbk 1 6/023 9 /352 'I �> Signs r " Telephone r;. ., w.,'; 6 , t.,, ,., .: 3. . 9 "£ , .; '" ;fit ;'!.,:!'z:7 Not Applicable ❑ e — c. onyI e 4e-TO_S 129 73 Company Name Registration N mber /3s t fW94L1 i» 12-1)1 og Address L Q 2 t� sZ7 o f la ti Expired n Da sou 1 { I �l p mil- (;)1 D'7 / Telephone? J-3 — SE!CTION-1Q = WORKERS' COMPENSATiOtINSURANCE F1DAV#T(044I".4 152 12• 6r} 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 ❑ 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 108.33.1. 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, vox 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 6 -. DESCRIPTION:OF RRfPOSED (check all.sobltcable) New House ❑ Addition ❑ Replacement Windows Alterations) ( Roofing ❑ Or Doors 0 Tr Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0] Other [0] Brief De tion of Propo ;gam, Work:. iVOU % Alteration of existing bedroom Yes ?ei No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes e .›G' No Plans Attached Roll - Sheet 4.' ":.. u_ ka.. a��. j.. v_& dt :.i4...d?,.j....a°4.a 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 ?a- OWNER AUTHOR TION - 3 8E ` IiiE ET N OWNERS AGENT ORZ COMTRACTOR APP4 IES F BUILDING MPT 1, M vied{ A. , as Owner of the subject property 1 ' hereby authorize ! >Lek v> ' - Ati A. - to act on n behalf, i all matte z ative to work authorized by this building permit application. V Signature wner Date 1, a& 4tJ Pi )q ' - , 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. abd4 -i2 i-h f s— Pd7Z4612,61-0-t------e-_____ /7) 2.6)t, Signature of 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 filled in by Building Department Lot Size € �i 2121 . Frontage Setbacks Front = 1 1 Side L:L.. ---1 R:L -.... _J L:t z R:l__ t i Rear f 1 � 3 ---I Building Height i t I i 1 Bldg. Square Footage 1 1 1 1% = = j Open Space Footage % (Lot area minus bldg & paved = = = t i leg) f r # of Park I 1 Parking Spaces : Fill: D I (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW 9 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book I Page[ 1 and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 9 DONT KNOW Q YES Q 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 1 C. Do any signs exist on the property? YES ® NO 1 __ IF YES, describe size, type and location: t i D. Are there any proposed changes to or additions of signs intended for the property ? YES © NO tri IF YES, describe size, type and location: I E. Will the construction activity disturb (clearing, grading, vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. eg ; City of Northampton Building Department . ; ° AL .10 Z"Lr' gq19..,'W■ Al" 212 Main Street Room 100 , Ft IN, yvv 1.\N\k 15 No ampton, MA 01060 0°04413 7-1240 Fax 413-587-1272 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 0 - ST t c-- T — e LCit Unit ,-** 0 Ov'ef14tstritt etriSt. Mettle ' CBDIstrIct - SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT . 3( 2.1 Owner of Record: Qove__A k , ; !OIL! ; VV o-v 0( o( c,)_. e(Print) • Curretg Adciress: ti Telephone 2.2 Authorized Agent: 0/ EP/thf /5.5 C-15/vd,1ir- ei) 3 <4 oirToili Nam • ;nt) Current Mailing Address: Alr Lii3 32-7 y Signature Telephone SECTION 3 - ESTIMATECCONSIRUCTRA1 COSTS Item Estimated Cost (Dollars) to be Official Use OrriY completed by permit applicant 1. Building penrit Fee (It 00 2. Electrical (b} Estimated Total Cost or Constniction from (61 3. Plumbing 13tiliding Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 2-410, 5 . , 6. Total=(1+2+3+4+5) A Check Number /VI04 Ibis Secticon For Official Use Only Date Building Permit Number Issued: Signature: Bulkfing CommissionerfinsPector of Buildings - Date File # BP- 2010 -1069 APPLICANT /CONTACT PERSON EDWARD P HAMEL ADDRESS/PHONE 155 Glendale Rd SOUTHAMPTON (413) 527 -0164 0 PROPERTY LOCATION 181 PROSPECT ST MAP 24D PARCEL 058 001 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 Fee Paid 6/ Typeof Construction: REPLACE PORCH LATTICE & DECKING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 020695 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9RMATION 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 5/2_7/10 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. T 41 PROSPECT ST BP- 2010 -1069 GIS #: COMMONWEALTH OF MASSACHUSETTS i, ip:Block: 24D - 058 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 -1069 Project # JS- 2010- 001570 Est. Cost: $7246.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: EDWARD P HAMEL 020695 Lot Size(sq. ft.): 3963.96 Owner: KALINA NORA R & JO ROESSLER Zoning: URB(100)/ Applicant: EDWARD P HAMEL AT: 181 PROSPECT ST Applicant Address: Phone: Insurance: 155 Glendale Rd (413) 527 -0164 0 SOUTHAMPTONMA01073 ISSUED ON :5/27/2010 0 :00 :00 TO PERFORM THE FOLLOWING WORK: REPLACE PORCH LATTICE & DECKING 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 5/27/2010 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo