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29-109 (3) RYAN ROAD .,..,..,..„..,_, ...... ti .., ,.. 4 . t il , . .. , t , ... 1 A .... , i '•;. ' 1 ';.; .9.9-it I 1, ii9 : 99 , . .... .,-; "i ', "N. -'• .., . :. . .:,. •.,..*. pA TTO I 1 ,ti! 1 t,-.!,:q., ? = ' I STORY Nip - 1 :• , t 1, .3".• 1 4 CICV9 k ill al 1 - 1. ,.. 11 LXLS : -.';':-,. E*fiCE ... ....... .....: . „._. . _. . , . 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 ppon(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 proces requires th at the building�artment 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 ----- -. - - -- - perm its in - conj the_buildi.ng.Termit 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 L ^ I, e � understand the above. (Home,, ner /resident's sign requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. - �- --tee _._ Address of work location S / /5 1 1 7 9 ✓ .. Y4 / c? /a 4 Z ti The Commonwealth of Massachusetts Department of Industrial Accidents _ .� � �� Office of Investigations • > 600 Washington Street —1 Boston, MA 02111 www.mass.gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/PIumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): Address: City /State/Zip: Phone. #: Are you an employer? Check the appropriate box: Type of project (required): / 1. El I am a employer with 4.. 0 I am a general contractor and I 6. 0 New construction employees (full and/or part- time).* have hired the sub- contractors listed on the attached sheet 7. 0 2. ❑ I am a sole proprietor or partner- Remodelmn o ship and have. no employees These sub - contractors have 8. ❑ Demolition working for me in any ca employees and have workers' capacity. ty. $ 9. 0 Building addition [No workers' comp. insurance comp..;nsurance. required:] 5. E We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a- homeowner -dsi - ll wo officers ve xercis .ir _�1 �gl bing repairs or additions myself [No workers' comp. righ of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. ❑ Other comp. insurance required } *Any applicant that checks box #1 must also fill out the section below showing their workcets' compensation policy information. t Homeowners who submit this affdavit: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. Iam 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' policy '' compensation olic declaration page (showing the policy number and expiration date). com P � P Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fne 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 fire of up to $250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby _certify under the pains and penalties ofperjwy that the information provided _above_is true _ Si 4. ture: I ate: Phone #: i -Official use only. Do nvt wrrte in this -a iii to be completed 6y city or town official City or. Town: Permit/License # Issuing Authority (circle one): V I_ 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 : License Number Address Expiration Date Signature Telephone 9. Reciisterei3 Homeflnitotovernent'Contracto „ : ;4 4. t ,., , ....._ A ,. , _. Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.GL. 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 ❑ 1x :.Nome; 4 The_current_exemption for "homeowners" was extended to include Owner Dwellings of one (1) or two(2) families k, Vi 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 ort ampton Prima ces, a e ` , -.- s- General- Laws- Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House El Addition El Replacement Windows Alteration(s) El Roofing t t Or Doors 0 Accessory Bldg. . Bldg. :121 Demolition ❑ New Signs [D] Decks [El Siding [D] Other [p] Brief Description of Proposed r -C f Work: rr,, pr,4 -F4 r'i('. -r I 17-.);" shod (Ay.. h kit) Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes v" No Attached Narrative Renovating unfinished basement Yes , - No Plans Attached Roll - Sheet 6a; If.Newli ruse14nd`oi addit onfio complete tt`re. ©11o�ii<�riq: 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 JJ n n /VA 4 J u J /C , as Owner /Authorized Agent herebyifieclare that the statements and inf on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. ;T /4 ,t , 1 /U ; / .r-1 Print Name 4 ID , Signature of 0 er /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 Frontage Setbacks Front Side L. R :.13 L ` R . Rear Building Height N1 S/ Bldg. Square Footage l % Open Space Footage (Lot area minus bldg & paved 85 parking) # of Parking Spaces Fill: (volume & Location) --- A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES . r IF YES: enter Book i E Pagel 1 and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 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 IF YES, describe size, type and location: D: Are tt re any propo changes to or a - loons o si inten e d ortieproperty ? YES 0 NO 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. �,'. ` V ',', `g �c$' ' .k. `' v 4� r /, fa ._ City of Northampton S ta1t �' ortre tit g r „ � ^ \'' '¢ uilding Department t y , k , ..-, , ..4" , o - 21 Main Street a . r S- �� r �� � ' 3 �x Room 100 � � t v t ® *it' i if o r't C , r'a'ta'" n .(4,. 2 Northampton, MA 01060 i r ,o � 4 C �I phone 41'.13- 587x1240 Fax 413- 587 -127 ,7,-- I E s ,, , " ,, � ` , v E . �.: _._ er i , s � 9-04' ' ar - na av 1 !q,C) 4P NSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING tir SECTION 1 - SITE INFORMATION 1.1 Property Address: This section to be completed by office Map Lot Unit S'? N " 1 AA f C,) p fl o ref) G2- , /j'f fa 0 (D (�, Zone Overlay District Elm St. District CB District • SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: �, q / .,. /i -- -- (Print) 7K' - - 41' - - -- - 9- - 9 k. - # , .t , f [� /' fn. t. am, a�:� A Oi��.^ Name Print Current Mailing Address: Telephone C y13) 7d - ?os/o Signatur ‘1"1) 4._"7- 2.2 Authorized Agent: S a■iv -c. /la f 4 -4)f ii ,.x.51 , Name (Print) Current Mailing Address: 1 [signature Telephone SECTION 3- ESTIMATED 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 Total Cost of / - Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection itt 6. Total (1 + 2 + 3 + 4 + 5) Check Number f� 5 _ t `'' This Section For Official Use Only __ Date Building Permit Number: Issued: Signature: Building Commissioner / Inspector of- Buildings Date File # BP- 2010 -0443 APPLICANT /CONTACT PERSON NAHLOVSKY JOANN ADDRESS /PHONE 574 RYAN RD FLORENCE (413) 727 -8080 0 PROPERTY LOCATION 574 RYAN RD MAP 29 PARCEL 109 001 ZONE URA(100) / /WSP II THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �Or✓ �G' Fee Paid Typeof Construction: ERECT 8 X 10 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 IN PRESENTED: r` ti. 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 0 1 --Z 2CCy Signature of Building Of 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. 574 RYAN RD BP- 2010 -0443 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29 - 109 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 -0443 Project # JS- 2010 - 000600 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq ft.): 21 170.16 Owner: NAHLOVSKY JOANN Zoning: URA(100) / /WSP II Applicant: NAHLOVSKY JOANN AT: 574 RYAN RD Applicant Address: Phone: Insurance: 574 RYAN RD (413) 727 -8080 0 FLORENCEMA01062 ISSUED ON :10/26/2009 0 :00 :00 TO PERFORM THE FOLLOWING WORK: ERECT 8 X 10 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: dt qv/ 10 ,etll 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 aid: Amount: Building 10/26/2009 0:00:00 $25.00 212 Main Street, Pho (417) 587 -1240, Fax: (413) 587 -1272 Building Col: inis:4' ner - Anthony Patillo