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42-078 (4) 9 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supers isor Specialt- " a„ License: CSSL-101196 1 DALE A SMITH zf' , (. ' 26 COLLEGE VIEW HEIG S SOUTH HADLEY MA 010' J..G,.. l)I Is Expiration Commissioner 07/07/2014 a M City of Northampton 0. H j„ Massachusetts w'� ' f{, ok'z" rG1 €,> " v, DEPARTMENT OF BUILDING INSPECTIONS ( " 1.._! „,,....,. . .., ,,,, 212 Main Street • Municipal Building -.6:t.', �~ Northampton, MA 01060 �s1 ‘'. 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 fie/she relides or intends to be, a one two family dwelling, attached or detached structures accessory to such use and/or farm struct es. A person who constructs more than one home in a two- year period - all not be considered a horn owner." The building d-•artment for the City of NorthaNiwton wants any person(s)who seek to use the home owner exemptio to act as their own constructs n supervisor, to be aware that by doing so you become respon-'ble for compliance with stat building codes and regulations. The inspection process requires t :t the building department be c lied to inspect work at various stages, which include foundation/footinq (before backfill), sonotube les (before pour), a rough building inspection (before work is con, ealed), insulation inspection if required) and a final building inspection. The building departme t requires these inspections be re the work is concealed, failure to secure these inspections can esult in failure to obtain a ce ificate of occupancy until the work can be inspected. If the homeowner hires oth.r trades to perform work(elect ical, plumbing & gas) the homeowner will be responsible to make sure th. the trades hired secure their proper permits in conjunction to the building permit issued, and that they et their required inspections',Failure of the individual trades to secure the permits and inspections as equired can DELAY the project,until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's signa re requesting exemption) I will call to schedule all required buil•• g inspections necessary for the building permit issued to me. Date Address of work location i N c • The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations - = }' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): UP't 5 V rift Address: Z6 Co L.CC 6( V/( i j E(6411 S City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I,LITa employer with 4. ❑ I am a general contractor and I ❑ ,..employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.El I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. n Building addition [No workers' comp. insurance comp.insurance.$ required.] 5. n We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions 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' 13.1-1 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 t DIA for insurance coverage verification. - Ido hereby certi nder t e ,'ins and penalties of perjury that the information provided above is true and correct. Signature: t •�° Date: Phone#: 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#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: (( Not Applicable ❑ Name of License Holder: h Css c. //q a.940 o/9 e (Ac /4/06 License /(� Addres Expiratio Date 6M Cis' 7)7 - Signature Telephone 9r'Registered Home Improvement Contractor Not Applicable ❑ Company Nime / Registration umb I/o/% ray /7 ki as-' fl Address Expira' n Dat Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G L c.:152,§25C(6)). f. 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 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 Northampton Ordinances, tate and Local Zo '•_Laws and State of Massachusetts General Laws Annotated. Homeowner Signature • SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) , New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing IT Or Doors IJ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E1 Siding[O] Other[ Brief Descriptiog.af-Pro sgfl r ,,�,, Work: _ �dJ.s'7`G!/ 14,S 4-0( /ee / �/(l/i9/9c u Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa camplete.the'foilowinq: 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 constructio'. 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 '. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or ellar floor below finished grade k. Will building conf. 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 7( I, CD(x/// ?C 4 ,ki"e r5" , as Owner of the subject l property hereby authorize —TOP //,/-7— L!?/ /ter (7)4t-e to act o behalf, in I ma rs r .ve to work authorized by this building perrfiit application. Signature of Owner 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 ang belief. Signed under the pans a d penalties of perjury. _Dk 4 Print Name Signature of Owner/Agent Date J 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 Dc. .m ent r- Lot Size ..... ; I_ _� _ i Frontage . , Setbacks Front 1 , S Side La R:' � L:!,_._, � j j i Rear R _ =• Building Height I 1 Bldg.Square Footage = ( % n i I --- Open Space Footage /o (Lot area minus bldg&paved ! —1 i , 1 f i parking) #of Parking Spaces 3 I I---I r Fill: EE f (volume&Location) I? A. Has a Special Permit/Variance/Finding ever seen issued for/on the site? NO Q DON'T KNOW 0 YES 0 IF YES, date issued:;: f i IF YES: Was the permit recorded at the Re:istry of Deeds? NO 0 DON'T KNOW 0 YES 0 IF YES: enter Book I Pagel and/or Document#1 1 B. Does the site contain a brook, body ►f water or wetlands? NO 0 DON'T KNOW 0 YES 0 IF YES, has a permit been or ne-d to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained , Date Issued: i C. Do any signs exist on the p-.perty? YES 0 NO (3 IF YES, describe size ype and location: j D. Are there any prop•sed changes to or additions of signs intended for the property? YES 0 NO 0 IF YES, desc .e size, type and location: 1 E. Will the c•'struction activity disturb(clearing, grading,excavation,or filling)over 1 acre or is it part of a common plan that wil disturb over 1 acre? YES 0 NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. co • . 55. . . , , ., . ,. . •DepartmeMt use only Cif of Northampton Status of Permit -. ,Buii.ing Department Curb-Cut/DrivewayPermit ,, ‘`` - � f 2' 2 Main Street • Sewer/Septic Availability . '= ' '; : i I ` ' 203 4 Room 100 Water•/Well Availability JU� N rth. pton, MA 01060 ! Two Sets of Structural Plans t 58 1240 Fax 413-587-1272 Plot/Site-Plana ; ', , Don'°FF TON MA01060 Other'Specify . ' APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -^SITE INFORMATION - 1.1 Property Address: �� - This section to be completed by office 902. &I/� Map ' Lot Unit ,Plfra q 1410 tif1,l0oZ y '>Zone � Overla District . , Elm St..District CB District-- SECTION 2=PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: qvt lb S �U (Aici<'� Na a(Prin Current Ma ilin Address: CG ' "/.� -� Telephone Signature 2.2 Authorized Agent: 0 . .am�t) _ Current Mailing Address: ah m 4 -✓' C 4/13-s32- (�,�3O Signature f 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 6. Total =(1 +2+3+4+5) OOt Check Number . . This Section For-Official Use Only _ -_ Date Building Permit Number Issued Signature - - Building Commissioner/Inspector of Buildings - Date 92 GLENDALE RD BP-2013-1187 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 42-078 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:FIRE DAMAGE BUILDING PERMIT Permit# BP-2013-1187 Project# JS-2013-001851 Est. Cost: $2000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DALE A SMITH 101196 Lot Size(sq. ft.): 25918.20 Owner: POWERS DAVID S Zoning: . Applicant: DALE A SMITH AT: 92 GLENDALE RD Applicant Address: Phone: Insurance: 26 COLLEGE VIEW HGTS (413) 536-6830 SOUTH HADLEYMA01075 ISSUED ON:6/12/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL INSULATED METAL CHIMNEY 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 6/12/2013 0:00:00 $55.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner