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Sr.- ..m7-+i- -- N��� - ii :..0► %Uy y ' �u r`3a•irus_±'9 ..) e � - " _ CEPF .TN,ENT OF BUILDING INSPECTIONS , b \=_—___-1-_- = cc / INSPECTCP 212 Main Strut • Municipal BuiIciin_ `� ° ,_� Northampton, MA 01060 TTl1M O Yi WTTNTV D E XE' R TION 4. A CKNOWL .E DGEMEN _ T rik.f . V 1,Li\ JuLiLiru i�. a�.a� — The State of Massachusetts allows the homeowner the richt under 780CMR 108.3.4 to act as his /her construction sups:- 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 I 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 bacldill). sonotube holes (before pour). a rough building inspection (before work is concea led -). insulation inspection (if required) and_afn buldin ein.wection. 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._ lithe 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 exemp it n) I will call to schedule all required building inspections :.,essary for the building permit issued to me. Date Address of work , location l ` fr - , .'\, The Commonwealth of Massachusetts _ Department of Industrial Accidents ' :r Office of Investigations '" =; i�j 600 Washington Street ^ J" Z Boston, _3L4 02111 `;��f www.mass.gov /dia Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /PIumbers Applicant Information Please Print Le 'ibly Name ( B usiness/Organization/Individual): qL \t,e 6 .}' Ca `t \ 7,ks- -1 ' Address: C b '( 1r,.D, v4*-.. ` � r City /State/Zip : \����1�"�� Phone #: 'I 6 3? 4 6 Y6 Are y u an employer? Check the appropriate box: Type of project (required): I. am a employer with (all 1 ?• E] I am a e the contractor and I ll and/or part-time).* have hired the e sub- contractors 6 ❑ New construction ?_ I am a sole proprietor or partner- listed on the attached sheet 7. KemodeLing f slip a�rl haven � ee These sub - contactors have g_ ❑ Demo;i ion noe to . s 1 working for me in any capacity. employees and have workers' I I[ o v✓nrkers' comp. insurance comp. T S1- cane.+ 9- ❑ Building addition I rewired] 5. ❑ We are a corporation and its 10_❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself [N o workers' comp. insurance ght of exemption per MGL 12. ❑ Roof repairs a r ce required..] t c. 152 §1(4), a nd we have no employees. [No workers' i' ❑ Other comb. insurance reed.] - - - - --' -iv applicant at coed oox i7.1 r »e also nit out me secnon =ow snowing their workers' comptmsanon . policy information_ T Homeowners who submit this affidavit indicatiaz they are doing all work and then hire outside contractors must submit a new affidavit indicating such. } Contractors that check this box must-arrarhed an additional sheet showing the name of the sub-contractors and sale whether ornot those entities have employees. If the sub-contactors-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 brie ()flip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Off of Investigations of the DLk for insurance coverage verification. I do hereby cerd - - . - - .arns ' penalti o 'duty that the information provided above is true and correct - if —S - — Date: �_4.. A 2 G 0 f - Phone #: Official' use oncf- Flo not write zu thL; area, to be conTlered by cuy or town official City or Town: Per-mit/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 Supervisor: Not Applicable ❑ P Name of License Holder : \` �eA>� \k e.SG 4-) C 5 & 3 " 6 u License Numb G aR�►, I: - , c? vQ � 1 �7Ila Address �l xpiration Date ' _._ __.. it , j Signature -lep .ne 9. Registered Home Improvement Contractor Not Applicable ❑ } v.'e_o Chi 4 2 Company Name Registratio Number Address ) Ilii . ) Expiration Date Telephone 37Y 6 vi ct., 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. - Home Owner Exemption 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. &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 rensible 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 assachusetts 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 assu es r sponsibility ,. compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning aw and Tate .f Massachusetts General Laws Annotated. Homeowner Signature A 111 s SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing n Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding [O] Other [p] Brief Description of Proposed _ p _ _ z - C ' l Work: �l�E'a/t 3 1 ") V� ' c >. �k' \ UC VIKQ_ �� C)V�xsL.. r �@ �'n"C � F 6 Alteration of existing bedroom Yes �No Adding new bedroom Yes I No� Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa If New house and or addition to existing housing, complete the following: 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? i I 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 I, <� �C^f ( , as Owner of the subject property hereby authorize ' ` Y2G31,1i1 1C` C• �� "''f1 to act on my behalf, in all matters relative to work authorized by this building permit application. etitilo Signature of Date I •� , -- l/N NY `O , as Own- u rized) (::_Ag6fitilereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge an belief. Signed under the pains and penalties of perjury. Print Name Signature of Ownrg'ent) Date L 4 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 8 1 i e Lot Size ' Frontage M© 144& Setbacks Front Side L:. R: L: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved narking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO Q DONT KNOW Q YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 1 YES Q IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES NO */ IF YES, describe size, type and location: ( set__ aAkc, v.e.,(- E. Will the construction a ctivity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO ,j ?► IF YES, then a Northampton Storm Water ManagernentPermit from the DPW is required. R ♦ v Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit �^ 212 Main Street Sewer /Septic Availability • ROOm 100 Water/Well Availability • Z Northampton, MA 01060 Two Sets of Structural Plans Q phone 4,1 -1 40 Fax 413- 587 -1272 Plot/Site Plans Other Specify AP- Pj TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION" SITE INFORMATION This section to be completed by office 1.1 Property Address: 1 C�� 3 5.- 37 o (LC�IJ -3[' Map Lot Unit 0 t0-6C?.__ Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT I i 2.1 pwner of Record: * tr•O•-•\e‘ C ;31 O - \' SA-- I Name (Print) Current Mailing Address: Li 13= 5,6 (r, 353 +i Telephone Si• 2.2 Authorized Agent: � Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 1 / 5 0(7) 0 (a) Building Permit Fee A. 2. Electrical -4- -� \ (b) Estimated Total Cost of QUO t ) Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number I /r 01/4 This Section For Official Use Only � Date Building Permit Number: Issued: Signature: Building Commissioner /Inspector ofBiildmgs Date File # BP- 2010 -0334 APPLICANT /CONTACT PERSON R DEAN ACHESON ADDRESS /PHONE P 0 BOX 1052 WILLIAMSBURG (413) 268 -0246 PROPERTY LOCATION 37 ORCHARD ST 379-4 'It'd MAP 25C PARCEL 144 001 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 [moo /4001 Fee Paid j� Typeof Construction: RENOVATE 3RD FLR BEDROOMS TO HOME OFFICE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 83968 3 sets of Plans / Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO 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 Demolition Delay .40" 4 6 - _sIr Signature of Building 0 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. s iARU ST BP -2010 -0334 7 COMMONWEALTH OF MASSACHUSETTS : 25C -144 CITY OF NORTHAMPTON PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS ; 't ` B DO NOT HAVE ACCESS TO THE GUA FUND (MG c.142A) Catiagcny: - renovation BUILDING P R1VI T BP-2010-0334 a cct # JS- 2009- 0Q1426 r t: $17000.00 1e: sio .00 PERMISSION IS HEREBY GRANTED TO: • . Mass; Contractor Licenses Grip; R DEAN ACHESON 83968 i ietsq, ft.) 8712.00 Owner: GETOFF SARAH B & CHRISTOPHER N SCANLON & MARY GETOFF tSRS(1001/ Applicant: R DEAN ACHESON AT - 37 ORCHARD ST Applicant Address: Phone: Insurance: P 0 BOX 1052 (413) 268 -0246 W I LLI AM SB URGMA01096 ISSUED ON :10/9/2009 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE 3RD FLR BEDROOMS TO HOME OFFICE (; THIS CARD SO IT IS VISIBLE FROM THE STREET inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: a' - Service: _ Meter: Footings: oughr - Rough: House # Foundation; Driveway Final: Final: Final: /4.2 , 3 - p `i Rough Frame: OJ$' ( gS) ` / 7-0'r ,Gas: Fire Department Fireplace/Chimney: Insulation: Final: Smoke: Final: ©� 17'121 / 9 Avi.4.1 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. 0 `C ' /' _ --- - 4* Certificate of Occupancy ' ..sig nature: FUTyhe: , Date Paid: Amount: Building 10/9/2009 0:00:00 $ 102,00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 '"kzie Building Commissioner - Anthony Patillo 5