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23C-102 (6) 565 RIVERSIDE DR BP-2007-0282 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:23C- 102 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2007-0282 Project# JS-2007-000428 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 10018.80 Owner: SAWICKI STANLEY J JR&HEIDI S Zoning:URB Applicant: SAWICKI STANLEY J JR & HEIDI S AT: 565 RIVERSIDE DR Applicant Address: Phone: Insurance: 565 RIVERSIDE DR (413) 586-1425 () FLORENCEMA01062 ISSUED ON:9/14/2006 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL WOODSTOVE IN BASEMENT 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 9/14/2006 0:00:00 $25.004375 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo _ - — s� � s t � ti-..:— ,F t Northampton 'i a( � ng Department ur ; w n Ir ` — - -- i21 \IMain Street aue �. 0 .®t ,\ oom 1M0A 0 ae , , : �`SP 2CC�ortpton, 01060 n � ' , 1 � er�� y�40 Fax 413-587-1272 PS " tteSPecr E phone 413- 7-1 liS APF}LICATION TO CONI:STFI CT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION[ 1.1 Property Address: This section to-be compretedbyoffice �: n 5 K,vei.f sc ,/�z Map Lot Ursa Rorence, hi9 OI 2 ;Zone Overlay Dist rct t- t .or*I- is ! _: _ CQ� trrcL SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: SfAivev \7"-Name(Print) Current Mailing Adsj ss: -G i'N� .\T/C. Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTIONS-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building (a),Building Permit Fee 2. Electrical Eol'onstructioTn from Costof 3. Plumbing (6) Building(bj Cstimated Permit ta Fee. 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4-4. 5) Check Number This.Section For Official Use Only Date Budding Permit.Number. Issued: • Signature: Date Building Commissioner/Inspector of Buildings 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 ._ Frontage Setbacks Front Side L:'...— R:_. L::_____ R:i � Rear ` Building Height Bldg. Square Footage % 7--- Open Space Footage (Lot area minus bldg&paved ■ parking) #of Parking Spaces Fill: !� (volume&Location) . � i A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:' IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW Q YES 0 IF YES: enter Book Page, ' and/or Document it: Y B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 NO Q IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO 0 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 O NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. r •SECTION 5-DESCRIPTION OF PROPOSED!WORK(check all-applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n Or Doors El Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [E Siding[CI] Other[Mt Brief Description of Proposed Work: I r.,S4i kL Car r t �l-c'+✓e.„ hfrcc_rn-(_tom Alteration of existing bedroom Yes `I No Adding new bedroom Yes `/ No Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll -Sheet sa;[f Niw douse.aifd=:orac dltfciiUizrsirlx :rs i:sTri: 'i e SMAZ: a. Use of building:One Family V Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? (`JO 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 Ta-OWNER AUTHORIZATION.-TO BE COMPLETED TWHEN OWNERS AGENT-OR CONTRACTOR APPLIES,FOR;.BUILDINGFPERMIT ,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 ,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. Print Name Signature of Owner/Agent Date SECTION 8-CONSTRUCTION.SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9e12ei EaltfI`o'm tfili arremeri .ConfFacto"' y '._"` ` t ` 71`` Not Applicable 0 Company Name Registration Number Address Expiration Date Telephone SECTION 40-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 ❑ 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 �1 • • i.. ,..(.7.-5-41.t."..4 p2,0 / /G '" •-),t 4. + . � � .) Ut,ti III artliiimpIon • ms_— 51aaaacfasctta'9 � E — DEPARTMENT OP Buu_DrNG INSPECTiO1dS 4 - ` !, \-4-7: . 212 Main Street ' Municipal Building Northampton, Mass. 01060 rimss"." WORKER'S CO\Q'FNSATION LC;SURANCE AFFIDAVIT L (1i ce•nsxlpermi ttcc) 1 ' v.,ith a pancipal place of bu iness/residence at: I _ (phone') , (sr r_.,tici ty/sta.tc/a p) do hereby certify, under the pains and penalties of perjury; that . ( ) NM employer providing the following worker's compensation cover-age for my , employees wor dng on this job: answ—n Concanv) (Pete). Nu..,zir_r) (Expiration Date) • • ( ) I am a sole proprietor, general contractor or homeowner (circie one) and have hired the consactgrs Listed below wbo have the following worker's coopenszdon policies: 0\lame of ConmIc o") (Innlrano Company/Polio NruSn_C) (t ?;Jlyduon DatC ) (Nit me of Conmezor) (I.nsuranca Comoa.ayiPo!ic; N111mcer) CE.ipirtion Dale) (Name of Comoro ) (Insurance Compan)•/Policy N;unbe.r) (Expiation Date) EName of Contractor) (Insurauca Company/Policy Number) (Expiation Date). (oaaeh_dditiooJ rboct if noccury to fncu&tarot—"nu—ion:pertaining to.11 coon-nao:a) ( ) I am a sole proprietor and bave no one woridng for me. ('4 I am.a home owner performing all the work myself NOTE:plesc be ev,art Lt.:4...toile hemea. ocro who ecaploy pesona to do r.fr^,-,y•>, —.:e,00 r rr;aa'•ork co..dss ui of not most 1.1=tJro:tmia is which the bomocn ocr n=idos or cc the p-oundo zppurtcoa=there wr ooc c-=.rl1y oca:d7cd to be cnployes,o„t the wock..ceo ccoa, _,itn Act(GL152_1=1(5D,_ppturtico by s hotnro0•-o far c bc=r-or__cr permit n_y evidence the Ic of man..of am e=;Iloy.r coder tho Wor ele Coon9aen.anna Act- : I t+ada'a-end that a copy of Lai,on-tomcat may be foe-,rarded to th.Dopo tmco¢of 1,A.-A1 Acctdoxi'Off o0 of lra,r+000 for Lb. c°ve't-S va irarioa a_-td th1 C•.iltar to locum'co'orogo tndcr torxion 25A of MOL 152 esn Icd to the tposirioa of c•imiaa!pe=-liict eoa'irmg of a fine of ttp to s1,500.00 ounce of up to ono year and coil pcoahia in 1:54 form of a Stop Work:Order sad a fin of S I00.00 t thy t zinit me t��, For dcp.rta+vJ u,c only )(,ZN`�f .�/4 `' l�CTIIlII �`t t1ID t)G` Si&Daztum of LicanscdPcr niLI= hate y r (-- Lzrf fax# lnitutt =* it ,.e,„.. , 4 DEPARTMENT OF BUILDING INSPECTIONS .4.44 'i 4- INSPECTOR 212 Main Street • Municipal Building '`>0�,= -' Northampton, MA 01060 , 01 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sup,:: ,• sor. 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)t 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 I, ��� -�P -,�„ 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 9 ' L.? -Q (.., Address of work location 6-65" ,i vc r S ) IJ-t b 'r Flo r e. i'v C-C Y. c .