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32C-277 ` \ L^«/ z��/Y1J&\ / �- ��\^/\/\/� w� ^' • '`~ ,,, _, .v�(l - ' ' k /r L'� � �' . "~/ \m -J \� /�/� ,, r\�� \4 F __:_________ ' ' 1 � r`. ~ / | ' ' . f / \ \ / � ! \ \ ! / ■ ; 11 \ i U /' / | i \ } `��- / ----' T - � \ ! ��ro'7'7 \ J�� ` ' / V . / . - \ \ H \ \��=-- —� _-_ � \ `~ - ---------- � TY\ \ } / \,,,. _` \ ' ` . \ | ( ~�^/\ ��n] '/ � i n -�" ~` ' ^1� z_ c - � C, '/ ~=_ / ' / k dO � ��r4 r��` \ \ . _ _________ _ _ �� ___� "�)��1r L � [�, ^,`v .. / ^ ' VY�r 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 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 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 the. .building 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 exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Address of work location M ' . The Commonwealth of Massachusetts --- Department of Industrial Accidents =t-'1 iz Office of Investigations • ° Washington Street ! � Boston , MA 02111 r • www.mass.gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): &-4 !k. pi" Address: C 1 eL 6''C gr City /State /Zip: tW (‘)A Phone. #: f ?e ¢62 Are you an employer? Check the appropriate box: Type of project (required): /,- 1. 0 I a employer with 4. fl I am a general contractor and I 6. N construction ployees (full and/or part-time).* have hired the sub- contractors 2. I am a sole proprietor or partner- listed on the attached sheet 7. 1 Remodeling hip employees These sub - contractors have 8. ❑ Deniolon s and have. no y working for me in any capacity. employees and have workers' Y p ty c 9 u Building addition [No- workers' comp: insurance omp -msu a e required.] 5. D We are a corporation and its 10.0 Electrical repairs or additions 3. i ana alaemeo aer- doing -a l work o ic_cr av er is d�th r _LLD Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no 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 iContractors that check this box most 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 worker' comp. policy number. I am an employer that is providing workers' compensation insurance for my employee& 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 fi of up to $250.00 a day against the violator: lie advised that a copy of this statement may be forwarded to the Office of Investigations of the R • for insurance coverage verification I do hereby certify tz e , , ' , , d penalties of perjury that the information provided _above isirue -and 1correct // 1t /o Signature: f , Date. qT 9 I) " Phone #: St G - 4- ` 7 - Official use only. Do not Write in this are., to -be completed by city or town offu:iaL 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 : A l- \J \ Iv l C1A-cc- 4:2s74 License Number 1D9 s � t t0 (JP 8 126 Address 1/(§1( Expiration Date Signature Telephone 9. Registered Home.liiiprovement or�t ctor ' .., i ..,.. ' 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 b7rig permit. Signed Affidavit Attached Yes No ❑ The_current_exemption for `homeowners" was extended to include Owner 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 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 o - — ampton • r: ina s ° a , - e - s- GeneralLaws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [D] Other [ID] Brief Description of Proposed Work: COASTKAri gb 4 - ►3 P, i-N 4 -esf r6 e -vtSl^ Alteration of existing bedroom Yes f N o Adding new bedroom Yes 0.--- No Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll - Sheet SL I NOWlioase and ort to°eicisting housing: :cointi ete ilie.follow>Incl: 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 C a MPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, f--LC-14- C-Lka-k— , as Owner of the subject property � hereby authorize Aufw f p.1 U 14k "&- to a b ehalf, ' all matters relative to work authorized by this building permit application. S 7 -1 —o ff Signet re o f wner Date 1, p (-m tr (A. to `A - , as Own /Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best o�ge and belief. Signed under the pains and penalties of perjury. AC.VVr f.k. Print Name / / Signature of 0 er /Ag Date , Section 4. ZONING All Information Must Be Completed. Permit Cart 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.i,_ _ _._.. L:._.~.~_._. ` R::_____ _ .. ___ t ♦x_£ Rear Building Height Bldg. Square Footage € ' % ~ Open Space Footage _ % (Lot area minus bldg & paved n , y— , parking) - # of Parking Spaces - -•- ------ -- Fill: I I (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 0 DONT KNOW YES IF YES: enter Book = Page I and /or Document ft mryµ ~ B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 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 (4 IF YES, describe size, type and - location: -. "� - - - - TS: t ere an ro osed - E an es t - or a itions O st is hailed for `the property ? YES 0 NO t Y P - g g P P Y• 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. itga Ek3rtTterlt jl�s�fli7l% • City of Northampton ` Building Department rb-t-ttadE %ray 212 Main it*INKAseK 91114 Room 100 A f. e � ' Northapton, MA 01060 phone 4- Fax 413 - 587 -1272 aN : ~ � #7,41 = AP ,1CATION'TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTI ©N ,a - SITE INFORMATION 1.1 Property Address: This section to be completed by office 94 wiLx_ Am,s Map Lot Unit Zo Overlay District Elm. St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: \ CC CAAsIcl Nam t) c Current Mailing Address: s-21 O Telephone Signatue 2.2 Authorized Agent: rw k 9 14A'19 MA 0103.E Name (Print) Current Mailing Address: .n9 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION. COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 4- 0 • (ii (a) Building Permit Fee 2. Electrical Ban (b) Estimated Total Cost of Construction from (6) 3. Plumbing 1 d p ON) Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) ( s ° Check Number 87)(0 This Section For Official Use Onfy Date Building Permit Number. Issued: Signature: Building- Commissioner/Inspector of Buildings -= Date File # BP- 2010 -0258 APPLICANT /CONTACT PERSON ALVIN HALL ADDRESS /PHONE 109 WEST ST HADLEY (413) 586 -4633 PROPERTY LOCATION 84 WILLIAMS ST MAP 32C PARCEL 277 001 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' � Fee Paid Typeof Construction: CONSTRUCT 2ND FLR BATH*DRESSING ROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 042574 3 sets of Plans / Plot Plan THE FOL3 OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 Signature of Building Oft al / 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 -0258 GIS #: COMMONWEALTH OF MASSACHUSETTS P _ , 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 -0258 Project # JS- 2010 - 000327 Est. Cost: $6800.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ALVIN HALL 042574 Lot Size(sq. ft.): 10410.84 Owner: CLARK RICKI D & MARCIA M ROE CLARK Zoning: URC(100)/ Applicant: ALVIN HALL AT: 84 WILLIAMS ST Applicant Address: Phone: Insurance: 109 WEST ST (413) 586 -4633 HADLEYMA01035 ISSUED ON:9/9/2009 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT 2ND FLR BATH & DRESSING ROOM 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 9/9/2009 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo