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42-162 City of Northampton a a - Massachusetts * i,„7. , DEPARTMENT OF BUILDING INSPECTIONS ! .,. 9 rte' � t '. a � 212 Main St reet • Building A's, 4 Northampton, MA 01060 s : w '‘. INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner 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 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 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 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 1, �A� „i1, 4-7 understand the above. (H ow ner /resident's signature requesting exemption) I will c to schedule all required building inspections necessary for the building permit issued to me. Date / / 01 Address of work location 7 3 C l 1°ilr/inir MI ! ( o rPrcr, • The Commonwealth of Massachusetts Department of Industrial Accidents " """" Office of Investigations =: 600 Washington Street ear " ' tm Boston, MA 02111 . www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders /Contractors /Electricians /Plumbers Applicant Information Please Print Legibly Name (Business /Organization/Individual): T S'S 1 c A /L+ IQ !\ 0 _ Address: (U 3 G- (cej X . City /State /Zip: r(' cedi /IG&, Phone #: `f /3 " 3L //'3rZ Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and /or part- time).* have hired the sub - contractors 6. ['New construction listed on the attached sheet. 7. El Remodeling 2. El I am a sole proprietor or partner- ship and have no employees These sub- dontractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. .Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions q ] oficers have exercised 11. Plumbing repairs I am a homeowner doing all work f h id their ❑ g airs or additions P myself. [No workers' comp. right of exemption per MGL 12. ❑ 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 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. 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. 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 fine of up to $250.00 a day against the violator. Be 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 of perjury that the information provided above is true and correct. Signature: �tr" Date: Phone . 5 3- ,3'r 3 CZ Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/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 #: (L` rr9J —1 r \ i 11 oo d >19M 1, 71 il v ot r � YadSvdOJc..\ 1 t vas ,ji C7A) , 1 a _ , avv rAt;E 135 t FNO. 0.98' SQUTN I.P. gyp• � Or 80UNOA \P t Y TWQ (2) LINES yO o OF WIRE FENCE _ - " 1 . a i �0�� ?� N r -- s�R ,.. a 3 1.P. FIN 0 oc 0,:. w x ` �- " ? G 0. 1 - 1- d r 04, 1.4 co 0 4 « 4 . O a t 1 S i P M r u a S 361 $ t. .... -co sr4 i D ^. Q r 11. a w a zio0 a _ 1. o z /� �, �'-} . o r • a 019 �,,� 1 r ,00 • LO T 2 295 S.F. `' ° ` � �� �'. AREA -- 115. \9d, ,___ • .� ` AR EA - 2.6468 ACRES '��.�: • � �.y ��. °o . . . \ *. ice+ \ f `J O. E � rj �yS �a 0� �9 ‘, \ ..". � \ ? � .> , " - a ad , lC \ **....N '• C ;,a SECTION 8 - CONSTRUCTION SERVICES I 8.1 Licensed Construction Supervisor. Not Applicable u Name of License HoLdee License Number Address Expiration Date Signature Telephone 9. Re iab)red 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 Exemntion 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 under the buildint= 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 Northampton Ordinances, to and ocal Zoning Laws and State of Massachusetts General Laws Annotated. 31 11 Homeowner Signet re Ilii, 1410 „ t SECTION 5- DESCRIPTION OF PROPOSED WORK (check a!! applicable) I I ,, 1 1 New House ❑ 1 Addition j� a Replacement Windows 4 Alteration(s) ❑ I Roofing ❑ Or Doors ❑ f Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [[D Siding [01 Other [p] Brief Description of Propose /, I ��p,,�,� jL,, / Work: k. rd I r i 4: a1J101 " Un ( &knAb 0r\ 0(114) Pe 0-( "r Alteration Alteration of existing bedroom i Yed ✓ No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes V No Plans Attached Roll - Sheet sa. If New house and or addition to existing housing, complete the following: a. Use / se of building : One Family.__ , ✓ Two Family Other b. Number of rooms in each family unit: l 0 Number of Bathrooms C. Is there a garage attached? i 2 d. Proposed Square footage of ne construction. J si Dimensions / ' X ail, i e. Number of stories? I f. Method of heating? JI P Fireplaces or Woodstoves /U //A Number of each Al if g. Energy Conservation C pliance. r"" Masscheck Energy Compliance form attached? h. Type of construction ,ft11 / i. Is construction within 100 ft. of wetlands? Yes V No. Is construction within 100 yr. floodplain Yes y No j. Depth of basement or cellar floor below finished grade "� �j JJJ k. WiII building conform to the Building and Zoning regulations? ✓ Yes No . I. Septic Tank A /fft City Sewer N/A Private well .N/A City water Supply N/4 SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, , 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 I, K"* `-- ' 1 OJ 2 , 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. )10_S .__( 0—/ ,/ Print Name Sgna . e of • r' /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 a...5 ►e C1C/I .Q) I NM i t , f ! I I Frontage J 0a (? J 4A Setbacks F 1 f 1 ' I ! . I L;)- ' R: H L:a't?tR: RC/ I i I 1 Rear ?,-' I VA i 1 I I Building Height a 'CO' 1. 1 Bldg. Square Footage 00 I as o a I Ey 3% I I Open Space Footage 1 ( _ % 1 q 1 I (Lot area minus bldg 87 paved Lt SCIO I 9 ' F 6 I 93 ; % I parking) I °` I # of Parking Spaces i 1 (voiuIL1&Lut8tiuz1) Fill: L J Q , I fI // 1 M+ I A. Has a S5'al Permit /Variance /Finding ever been issued for /on the site? NO i DONT KNOW 0 YES 0 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 Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO er DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained €porn the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO er IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO er IF YES, describe size, type and location: F Will the construction activity disturb (clearing, grading, exca ion, or filling) over 1 aexa or is it part of a common plan that watt disturb over 1 acre? YES 0 NO ii= YES, then a Northampton Storm Water Management Permit from the DPW is required Depardxtent use only RECEIV City of Northampton Building t is 1R it Curb CutiDdveway Peimit I { DEC 52012 212 MDepartment ain Str sewer/Septle Availability Room 3 00 Vater /Weil Availability N hamoton, MA 01060 Tv Sets of Structural Plans DI FT OF BUC_D N , r t 'J 1 T OFBU °T IG ON. Mi,* �4ftg 41 587-1240 Fax 413-587-1272 Iother Plot/Ste Sped#fy APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING i SECTION 1 - SITE INFORMATION 1 1 1.1 Property Address. This section to be completed by office 3 /� 41 Map Lot Unit �}- [b tL i lL /`— ,,\\ Zone Overlay District l rO i��� // YL Eim St District C€s`District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT I 1 2.1 Owner of Record: Q 11,)?-) (LLri, t � °..U7 - J Y M Name (P Current Mau' Address: ■ A 1 r 4-t �f r . f V Telephone Signet e 2.2 Authorized Anent: 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 (f o.Af' ^ ` ^) ( t o 0 0. 00 (a) Building Permit Fee i I 2. Electrical " 1 r (b) Estimated Total Cost of ! 11 Construction from (6) i 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection �1 ' I 1 6. Total - (1 +2 + 3 + 4 + 5) i .b �� 0 0. 0 0 1 Check Number // Ot 0 76 1 S This Section For Official Use Only Building Permit Humber: = Date I Issued: Signature: Building Commissioner/Inspector of Buildings Date File # BP- 2013 -0628 APPLICANT /CONTACT PERSON DELANO JESSICA A ADDRESS /PHONE 103 GLENDALE RD FLORENCE (413) 341 -3666 Q PROPERTY LOCATION 103 GLENDALE RD MAP 42 PARCEL 162 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out i pi; Fee Paid Typeof Construction:_CONSTRUCT ATT GARAGE ADDITION FOUNDATION ONLY (16 X 24) 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 INF9RMATION PRESENTED: tr 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 Per nit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay / / / 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. 103 GLENDALE RD BP- 2013 -0628 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 42 - 162 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- 2013 -0628 Project # JS- 2013- 001017 Est. Cost: $2200.00 Fee: $76.80 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 102627.36 Owner: DELANO JESSICA A Zoning: Applicant: DELANO JESSICA A AT: 103 GLENDALE RD Applicant Address: Phone: Insurance: 103 GLENDALE RD (413) 341 -3666 () FLORENCEMA01062 ISSUED ON:12/7/2012 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT ATT GARAGE ADDITION FOUNDATION ONLY (16 X 24) 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 12/7/2012 0:00:00 $76.80 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner