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Z )5 J.77 I i 2,is ...c ..,..... ...„- -..„ r1 ,... ) „ fi I .. • , 1 ' C 5 I 9 / 1 , _ 7 , / , .,,,J,,-, , .., ii , , ,, rt 1 / c)-- ----- , c Z.,' „.. ,-, cb yae/V4 - 1 fill 7 , , 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 °construetion 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 buildina (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'insected. 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 h 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 1 5. . Z. . • • . • The Commonwealth opfassachusetts • Department of Industrial Accidents . ' Office o [Investigations • 600 Washington Street 1 n ...- Boston, MA 02111 . "......,,, , www.mass.gov/cha -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name pusineseorganizationfindividp.D: --) i "/ / irk, ,----- . • • Address: o ld 3 --- AioyeIlA City/State/Zip: t, de e t E - C -e fit At Phone.#: Are you an employer?. Check the appropriate box: • • Type of project (required): 1.0 I am a employer with • 4• 0 I am a general contractor ancl I 6.. 1...) ■---. N — ew construction emplriyees ilidlOr plitztiniCe).* haw hired gle - stth -e m itraeters 2. I am a sole proprietor or partner- listed on the attached sheet 7. 0 R.emodeling ship have no employees These sub-contractors have- g 0 Demolition working for me in any capacity. employees and have workers 9. 0 Building addition [No workers' comp. insurance cnnaP. insurance-. - , Electncal repairs or additions . . requ . • 5. 0 We are a corporation and its 10.11 S 3.0 I am a homeowner doing all work officers havelxercised their • 11.0 Plumbing repairs or additions myself [No workers' c d m p. right of exemption per MGL 12.0 Roof repairs insurance requir' ed.] t . c. 152, §1(4), and we have no employees. [No workers' 13 -U Other ' - - comp. insurance required.1 . *Any applicant that checIts box #1 must also fill out the section below showing their workers' compensation policy infomation. " • t Homeowners who submit this affidairit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1 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. . Jam 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. Lie. tfr: 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 aral/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $25000 a day against the violator. Be advised that a copy of this statement may be forwarded to the Offibe of Investigations of the DIA for insurance coverage verification. Iilo hereby certi nder the , alas an penalties of perjury that the information provided above is tru and correct • • ' de Signature- - •• , 'Date: . l / / • . • Phone ti: c..// - ,, , , 2 1 0 d - ----- t i, ..r • • • COffityicotair Town only. . • Permit/License # y. Do not write in this area, to be completed by city or town official Issuing Authority (circle one): • .1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical,Inspector 5. Plumbing Inspector 6. Other t- • Contact Person: • Phone #: 1 , • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor. / Not Applicable ❑ Name of License Holder : fit e. r1 / License Number t • Addre � Expiration p Signatu !( ` l am" /S. A/ 4 ��� , Telephone 9. Renistered Home Improvement Contractor. 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. - 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. 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 ender 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, von 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 / eV /1/ e de j k._ )4e -e 7 s j t .e J 4- p ee ,fr., 7 7 5 6te; 2 i / £ )ci e, s I / - e in 4, 0 44- /--ry / 7, cft< ,J , 7 --- rt . n , „.„ _ I r c „4„,ete 77 1 i i / 9 - i ' 7 , L ' ..., p- c c7 / r / e 7 I 1 5 lye es_ I cl X_ 7 ,, --‹ , ,{) ii- I f k ,d ir2 ''. ci ' • ' ..7 s'--- ," C - dp - r-- - .- --,,, dieC1 ; f p 4. Le. leo sy /e-r ) 4, ro .FIl ei . , . 'S 5 ,-7;1.'6 ,,,,, rr. ; / / -,' I 0 ie Co A) 4 A ; ft-5 7 5"-? rk '' .(-1-7 C / ----_________________............................___ • SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition rZt Replacement Windows Alteration(s) ❑ Roofing El Or Doors [� Accessory Bldg. ❑ Demolition ❑ New Signs [a] Decks [El Siding [CI] Other [Li) Brief Description of Proposed l Work: Ct dt,� 7 Lt O �� ` K f � -L ct ` `G � e Cte Se Ai 6 Alteration of a fisting bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. 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? 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, l " r ` . , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit a i ion. Signature nn re of 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. T " /1,4-ire Print Name 7/// Signature of Owner? / 1r! Date Section 4. ZONING Alt 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 /; frri Frontage � ' 1 1577 Setbacks Front h Side L: J R L: ! i Rear Building Height Bldg. Square Footage : a ( ' O ' % (f 7 0 �y Open Space Footage ' 7 yik7 % 7 7o ( 7 3 } l q (Lot area minus bldg & paved / ( parking) ( / - # of Parking Spaces 6 G7 Fill: / (volume & Location)! - A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW ® YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO O DONT KNOW O YES O IF YES: enter Book Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ' DONT KNOW O YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES O NO O IF YES, describe size, type and location: E Will the construction activity disturb ( ring. grading, excavation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES NO f j IF YES, then a Northampton Storm Water Management Permit from the DPW is required. t L • Department use only II City of Northampton Status of Permit • Building Department Curb Cut/Driveway Permit 5 0 212 Main Street Sewer /Septic Availability Room 100 Water/VVell Availability ry ampton, MA 01060 Two Sets of Structural Plans • • - 4i3- 587 -1240 Fax 413 -587 -1272 Plot/Site Plans -. • * -- Other Specify pecify I APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Property Address: __,i This section to be completed by office 7 it f f i ' t c .1J S I Map Lot Unit f Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: id s crT inn , �t < 9I g. ,mac, e rte , .c - i •e-' _= Name (Print) Current Maw ti ,.rito ,_ �` Signature Telephone ' r / S J J• / 6 rY As s 2.2 Authorized /Went: (y( T ,„ ,� /I 4-e e ;-7-<,,/ .i 3 i t, ., ,vc 7 C -, 0 :7 — y f ,? et <7 - E '. Name (P ' t) Current Making Address: z:// 7 6 a �- C, Signet Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS i Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building f � .0., e ' (a) Building Permit Fee 2. Electrical „ 1 - ) (b) Estimated Total Cost of Construction from (6) 3. Plumbing ,S -) C+ ea' Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) - ' L' �,> Check Number /475 I� his Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/lnspector of Buildings Date File # BP- 2012 -0007 ? III �,f3 0 I� I ` OJT 9� V ek AAJ I APPLICANT /CONTACT PERSON JAMES HARRITY ADDRESS/PHONE 225 NONOTUCK ST FLORENCE (413) 210 -5256 O PROPERTY LOCATION 47 UNION ST MAP 32A PARCEL 068 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out >!� v% / 9 0 Fee Paid /(p Tvpeof Construction: CONSTRUCT 14 X 20 ADDITION New Construction Non Structural interior renovations Addition to Existin& Accessory Structure Building Plans Included: Owner/ Statement or License 052260 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 D • molition Delay ,� 7-- �7 Sit . 1 e 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. F 47 UNION ST BP- 2012 -0007 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32A - 068 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 -0007 Project # JS- 2011- 001778 Est. Cost: $23000.00 Fee: $148.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAMES HARRITY 052260 Lot Size(sq. ft.): 10541.52 Owner: WADE ROBERT N & AUDREY S Zoning: URC(100)/ Applicant: JAMES HARRITY AT: 47 UNION ST Applicant Address: Phone: Insurance: 225 NONOTUCK ST (413) 210 -5256 0 FLORENCEMA01062 ISSUED ON: 7/8/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT 14 X 20 ADDITION 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 7/8/2011 0:00:00 $148.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner