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31A-180 (2)
City of Northampton t7(`, -: Massachusetts wzs c ` ' 7Z-II,:;" .'Y� ,"'IT h4 ; DEPARTMENT OF BUILDING INSPECTIONS b t'4 F' cr br 212 Main Street • Municipal Building a .� Northampton, MA 01060 se a jft 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 jbefore 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 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. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street IMMIX t r Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Key,AL) ho i..i e j t ) 13 v9l Address: / +j %1 PPEL 0.4-P9197- kt c4- 0-4> CVN rJ 4'Y /IMF- City/State/Zip: co vw kY i M 4. 015 41 Phone #: 41? -30-4-3 z 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 loyees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. E] Remodeling These sub-contractors have ship and have no employees 8. El Demolition working for me in any capacity. employees and have workers' 9. Li 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.❑ 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. Ido hereby certify under the pains ndpena '',s of perjury that the information provided above is true and correct. Signature: Ki/v—v---, Date: (Q /7.-91i3 Phone#: *13 `' 30"-'4-3 2- —— 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: KEij/(N ft ‘b>0 14..)N' 1 E 0 4-1pC-/-3 License Number /40 14 PPE 4K u- , NCO/ L'K'() MA- 0 144) o3lnz/ i 5 Address Expira on Da 4-13—30i-1- 3 2 Signature Telephone 9 Registered Home Improvement Contractor _____•.___ _ �4s „� 7.71; Not Applicable ❑ rsotA:wie grins. CO Arreil-CM06 V-FrnN buWNiE I o 5S?-c Company Name ) Registration Number 1,4-v vt©PEf - 13,wcis-r bh u_ 2a, - Address Expiration Date 0)MAJ�!/ M, 0/3j+/ Telephone4/3 —31rQ i 3) c7312_1 /201 1- 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 buildin 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, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature • a • SECTION 5--DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n Or Doors D Accessory Bldg. ❑ Demolition New Signs [0] Decks [D Siding[0] Other[0] Brief Description of Proposed Work: bFiMO 1S ('.�h 4rJ eO C. g Dc �-D CSC Alteration of existing bedroom Yes ?-"No Adding new bedroom Yes ✓ No Attached Narrative Renovating unfinished basement Yes 17-No Plans Attached Roll -Sheet fa: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, 1 i4- -)>1 6(a ,as Owner of the subject property hereby authorize }-I✓1/tA) t0(A) to act on my behalf, in all matters relative to • , authorized by this building permit application. Sign-t re of Owner Date I, 0 'D W,j t E ,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. SignecLunder_the pains and penalties of perjury. k 1 v'I n) F l)o pvN f 6 Print Name . - r C 4017,,q1/3 Sig atu e of Owner/Agent Date 4 Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information e Existing Proposed Required by'Loning This column to be filled in by Building Department Lot Size ' 1 Frontage ' Setbacks Front Side L: R:! L:(_—_2, R:' 1 # Rear I 1- ' Building Height _ 3 Bldg. Square Footage I I I % I # Open Space Footage (Lot area minus bldg&paved i 1 - , 1 parking) #of Parking Spaces i I Fill: i i j (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW YES Q IF YES, date issued:s IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES 0 IF YES: enter Book I i Pagel = and/or Document#I 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 Q Obtained , Date Issued: i 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 0 NO IF YES, describe size, type and location: l E. Will the construction activity disturb(clearing, grading,exc ton, 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. S Departmemt use only City of Northampton Status of Permit r°_, f!,,.,.'_. 1 B 'Wing Department Curb Cut/Driveway Permit'. �- � , _� 12 Main Street • Sewer/SepticAvailablllty rtil/t4 Room 100 Water/Well Availability 2 ,,.'sue l ort 'npton, MA 01060 TwoSits of Structural Plans t phone 41.-5 7-1240 Fax 413-587-1272 PIotSIte Plans k t_ . _ .;, Other Secify — APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION - This section to be completed by office 1.1 Property Address: ,- 2-3 IN' 1■ C.,4'brJ G ' Map Lot Unit Zone:!- = Overlay District..: - Elm St District CB Distncf' = SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT _ 2.1 Owner of Record: TN-eA HF-A-0'b 16 C Z ki rJ 4-�r3 Ate'. , iv 0.R= sr4txtvA) Name(Print Current tailing Address: � �� l `� x-13 -- �$�--SsgR�'j �t� �///r` Telephone Sign. . e `. 2.2 Authorized Agent: 61/lnl °Nn�,JN 140 v1PPC� IISMT 1t�►I,L. 0z>•I co&+�'Y/ MA Name(Print) Current Mailing Address: 0 I�. - L 113 -- 361 -1-3?2_ Signatur 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 con struction'from (6) 3. Plumbing Building Permit Fee = 4. Mechanical (HVAC) = 5. Fire Protection Check Number 6. Total=(1 +2+3+4+5) ' - This SectionFor Official Use Only � - - =! ' = Date - Buildin Permit Number _:` : 9 ... . ' Issued. ! - -Signature.. . -_ _ Building Commissioner/Inspector of Buildings : `Date File#BP-2013-1250 APPLICANT/CONTACT PERSON KEVIN F DOWNIE ADDRESS/PHONE 140 UPPER BAPTIST HILL RD CONWAY (413)522-7711 PROPERTY LOCATION 23 WASHINGTON AVE MAP 31A PARCEL 180 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ‘OP' \pLb Fee Paid 'J Typeof Construction: DEMOLISH CHIMNEY New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 46673 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO 3MATION PRESENTED: L/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 De, o 'tion Delay /e 2-2 -4? Signature of Building •fficia 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. 23 WASHINGTON AVE BP-2013-1250 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31A- 180 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2013-1250 Project# JS-2013-002059 Est. Cost: $1000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: Liccusc: Use Group: KEVIN F DOWNIE 46673 Lot Size(sq. ft.): 11456.28 Owner: HARDIGG THEA CATHARINE BELDEN Zoning: URB(100)/ Applicant: KEVIN F DOWNIE AT: 23 WASHINGTON AVE Applicant Address: Phone: Insurance: 140 UPPER BAPTIST HILL RD (413) 522-7711 CONWAYMA01341 ISSUED ON:7/9/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:DEMOLISH 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 7/2/2013 0:00:00 $25.00 212 Main Street, Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck-Building Commissioner