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23D-008 (3) + C • BP-2008-0488 GIS #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:roofing BUILDING PERMIT Permit# BP-2008-0488 Project# JS-2008-000731 Est. Cost: $7000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CRAIG JOHNS 154650 Lot Size(sq. ft.): 10018.80 Owner: DEIHL DOUGLAS&JANE NIEJADLIK Zoning: URB Applicant: CRAIG JOHNS AT: 54 NONOTUCK ST Applicant Address: Phone: Insurance: P 0 BOX 52 (413) 695-2757 C U M M I N GTO N MA01026 ISSUED ON:11/7/2007 0:00:00 TO PERFORM THE FOLLOWING WORK:REROOF MANSARD ROOF 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 11/7/2007 0:00:00 $25.002875 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo . Department use only City of Northampton Status of permit:, ; Building Department Cuts Cut/Driveway Permit 212 Main Street Sewer/SeptieAyaitabrlity wC� Room 100 Water/Well Availabil t Northa pton, MA 01060 Two Sets ofStructural Plans' ph 41.3-587240 Fax 413-587-1272 plot/Site Plans Other Specify APFILICATION 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: / :d A'G ti; S'7", Map Lot Unit F Le) e c.-E /4 - z- TT Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 12.1 Owner of Record: c>� 1115 /41.0e ih s=7„/e Name(Print) ° ( Current Mailing Address: Telephone `` Signat6tV t q/l 2.2 Authorized Agent: 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 (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) Check Number 02775” This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commissioner/Inspector of uildmgs 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 �------- - ________--_-____ ___-____-'____-_ Frontage .______________JL-____� -____- Setbacks Front �--- �---7 �--- - Side - Side Rear �---7 �---- !---- �_~ __- DuildingDoight Bldg. Square Footage cl/0 r--� F---1 !---� ,„, _ �� Open Space Footage (Lot area minus bldg&paved oaruino #of Parking Spaces ---- ---- ---- Fill: ------------- -- --------� -------' -------� (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? �� 0 NO 0��� DONTKNOVY «_� YES v�� [--------� IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO � �~��~� DDN7KNOYY �-\ YES �-\ .--------�-� �� r ) ----- �--` r----------� IF YES: enter Book Page and/or Document# _ B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained »-\ Date |ssued' �_� . ' � C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES »�� NU 0 IF YES, describe size, type and location: E Wrllthe construction activity disturb(clearing,ng,gradingexcavation, or filling)over 1 acre orish part ofo common plan that will disturb over 1 acre'2 YESK ) NO [ ) �� �� IF YES, then a Northampton Stbrm Water Mrfagement Permit from the DPW is required. • SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Xi Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [I= Siding[0] Other[CO Brief Description of Proposed Work: h_)/76W/ LAltA45/'.4,-6i# d-e9 Alteration of existing bedroom Yes Y No Adding new bedroom Yes ,v— No Attached Narrative Renovating unfinished basement Yes P No Plans Attached Roll -Sheet 6a If New house and or-addition.to--existing hoosing,_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, t2 °/q /2 J/ , as Owner of the subject property ,• -'-' �yS hereby authorise. q(, '�z to act on my-behalf, in all ma - r latfv=4' or.9'orized by this building permit application. Sigrtat of Owner 7 Date I, 4i/`(A,I, 1J 4i/[ S , as Owner/Authorized Agent hereby d clare 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. g t ki ' Print Name Signature of 0 e 'Tent Da e \T ` - SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: / J j t7j/t✓/ 5 !/` License Number ; ©�c `� /4/ -Row Q, /0/' ' to zoss Address Expiration D 1h/iM A,q-+ /lc . (/0 4 1/13 ( 75--'2 7-5-I Signa 7 E J Telephone 9.Regis�e d Home Irrtprovernent Contactor: "" ..._ .. Not Applicable ❑ L-(5'4.s o .. Com an Name Registration Number Fade c-,. L1 a 140 5- 3/z 8/ c�so y Address J `� Expiration bate ��1 c/iy3 /✓L,ta,)0,7-iit ili,re 1 Telephone /3 ‘?,S'27c i _ / /11,,, 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 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 } _ The Commonwealth of Massachusetts Department of Industrial Accidents i ;�' Office of Investigations Ss _; ; 600 Washington Street i. 7' Boston, .4 02111 Boston 11 1 � '� www.massgov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AnDIicant Information .--- Please Print Leg.iblti Name(Business/Organization/Indivichino: �fai/4 v JDh,✓, Address: ��/ S Z / 4/3 yyi j lir�, Cl tY/S tate/ZI P r/ 1 ��✓ t � ✓ 1� ®l�Z Phone 9/ 13 G>>S 51 Are you an employer?Check t ie appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a°ene-al contractor and I employees(foil and/or part-time).* have hired the sub-contractors 6. ❑New construction 12. I am a sole proprietor or partner- These on the attached sheer 7. ❑Remodeling ship a�ri have.no e 1oyees These sub-contractors have 8. ❑Demolition Iworking for me in any capacity. employees and have workers' I 9. ❑Building addition [No workers' comp:Msuiauce r, comp.insurance.* I I rewired] 5 W e are a corporation and its 10.❑Electrical repairs or additions 1J . officers have exercised their 11.❑Plumbing repairs or additions 3.❑ I am a homeowner doing all work myself. [No workers' comp. right of exemption per MGL 12.iii Roof repairs insurance required.]t c. 152, §1(4), and we have no employees.[No workers' 13.0 Other comp.insurance required.] '_-tnv applicant that checks oox Fd.must also nil out the sermon oe:ows/towing them 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.ariarhed an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-conuactors,have employee,they must provide their workers'comp.policy number. Iam 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 Sire 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 ofMGL c. 152 can lead to the imposition of criminal penalties of a fine up to 51;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 5250.00 a , v against the violator. Be advised that a copy of this statement may be forwarded to the Office of tig Invesations ..y DL4 for insurance coverage verification. I do hereby ry 47 14 der the pains and penalties of perjury that the information provided above is true and correct. ,•, ,f Date: Phone#: L ti ,C 5 7a — jj Off ciai use only. Do not wrue in this area,tb be completed by ciyv or town official II official City or Town: _ - __ -__-Per-mit/License Issuing Authority(circle one): 1.Board of Health 2_Building Department 3. City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector 6. Other Contact Person: Phone T: I . ,..,, .:.,______,,„ . . :,,..., .._. ,.. ,..._ . ?s jfassacirusets 1^I -- 1. DEFT'R.T MENT OF BUILDING INSPECTIONS \1° _�l/ 212 Main Street • Municipal B wilding INSPECTOR Northampton, MA 01060 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 , ior. 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..departr-neat for the City of Northampton wants any person(s)who seek to use the hone 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 bacl;fill). sonotube holes (before pour). a rough building inspection(before work is concealed).insulation.inspection (if required) and_afnad 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_iuspe tell._ 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. t Date Address of work location