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32C-151 (14) 9 ii i O)AS a C) ,T Ell f -- i ti � I tl � tt �� Cl s f CD i t Fy 1 ■ N DO 00 Ol N Ul N N N C) N >0 , O CJJ -y d� .,� C� -4 O 00 W O N � 1 ♦ 00 � O -o DEPARTMENT G EUII.DrhG LN5PE'"t"I0_NS 212 M.iin.Strut * Muuicipd BuildM-2 lNSPECTCP Nortfi<unpton, MA 01060 HOME ONVINER EXEMPTION ACbNnWL EDG-EMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as ;.islher construction supe.-."Or. 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 d'vellang, 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 shaiI not be considered a home owner." The building-department for the City of Northampton wants any per sons)who seek to use the home owner exemption, to act as their own constr uction supe z:sc; 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 back-fill). so-notube holes (before pour) a rough building inspection (before work is concealed). insulation ins-pection (if reunired)anda- inaI_buildina.insnection. The building department requires these inspections before the work is conceited, failure to secure these inspections can result in failure to obtain a certificate of occupancv until&e wart-,can-be inspected.. If the homeowner hires other trades to perform work(electrical, plumbing&gas) the homeowner will I 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 DFIAY 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 Ylassachuse,rs -- — Department of In dustrial.-I ccidents ©jiice of lnvestigarions �u =� 600 Washington Street .�=z' Boston, U4 0 111 �� wzvw.mass.gov/dia Workers' Compensation Insurance Affldavrt: Buil ders/Contractnrs/Electricians/Plumbers A>7 lacant Information Please Print Le4ibIv Name (Busmess/org,=z=on/Individual): Address: 1 l 11 C-r�istati✓/z; olo 7� t Phone. 7`�,�U Are you an employer?Check the appropriate box: Type of project(required): 4. I am a general contractor and I 1_ I am a employer with 6. E]-New construction empioyees(full and/or part-time)_ have hired the sub-contractors I ?. 1 am a sole proprietor or partner- listed on the attached sheet- 7. ❑Remodeling I ship and have no employees These sub-contractors have ,� , �. ❑Demolifon worlcng for me in any capacity. employes and have worlr. ' [No workers comp.insurance cow.insurance.+ 9. Builain�addition requirtc] 5. E] We are a corporation and its I0.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work o racers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'camp. right of exemption per MGL 12.Q Roof repairs insurance required-]t c. I52,§I(4),and we have no employees. [No workers' 13.[1 Other com=_.insurance required.) cnecrz oox FF1 nmst atso rW out tae secaon oe:ow saowm -- --- g err work='cott;ensanoa.policy infor�tioa 'Homeowne s who submit this affidavit indicating they are doing all work and then hire outside contrac.ors must submit a new affidavit indicating,such_ 'Contractors that check this box must-attached an additional sheet showing the name of the sub-coutcactors and state wnether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'corm.policy number. I am an employer that is providing workers'co mpensazion insurance for my employees Below is the policy and job site rnformaz;:on. Insurance Company Name: Policy#or Self-ins.Lic. _1 O O �o /Expiration Date: y--/O (� _ Job Site Address: r � V l City/State/Zip- Attach a copy of the workers' compensation policy declaration pane(showing the policy number and expiration date). Failure to secse coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a fne up to$1,500.00 and/or one-year as well as civil penalties in the form ofa STOP WORK ORDER and a 5-me of up to 3250.00 a day against file violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DLA for insurance coverage verification. I do hereby ceri under the parns and penalties of perjury that the informazion provided above is true and correct A- 4 ----- - - 7 Phone=: vfflcuu use only. vo not wrrte rn this area, to be completed by city or town offciaL City or Town: __ _Per-mit'License Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk ?.Electrical Inspector 5.PIumbing Inspector 6. Other Contact Person: Phone SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: 6e1'Ltl (� ���wr i 4 N6 -7 u 0 License Number Address Expiration Date E;j-9T11JTe Telephone 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number 1 � t W!UP I- Z l- _22- 6 7 Address - J 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 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-vear 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors I] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [$f Siding[0] Other[Q] Brief Description of Proposed 71 / �^ �n, I 1- / ,p Work: f,rt l X l'a I✓eM� OFT a 1 b Se -ll�P-mrY 2 eXl-5-f i �dx ,6 S Alteration of existing bedroom Yes Y_ No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa 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' S as Owner of the subject property hereby authorize to act on my be If, in all ma ers relative to work authorized by this building permit application. _ L6 b Signature of Owne bate I, l� - k k 'I t-f7JyL!i F 'rui L't as Owner/Authorized Aqent 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. Prin Name Signature of Owner/Agent Date • ' ti 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:__3i LJO .. R: -3....: Rear Q Building Height Bldg. Square Footage Open Space Footage % (Lot area minus bldg&paved 31O parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page and/or Document# 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 0 Obtained Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES NO 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 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. t - , Department use only City of Northampton Status of Permit: Building Department Curb Gut(Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot(Site Plaits Pther Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION ;" C1 �c; c/ 1.1 Property Address: This sb on to be completed by office Q ������0. �� '� 1 OCTM4 3 200 Lot Unit A C' Zone _ I Overlay District i D p F< Elini Dist}Igf,€� CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Prin Curren Mai ng Addr ss: L 2: Telephone Signature 2.2 Authorized jAgent: `f' � a'�'+t /J��ij— ?I ��P�S ic�St' 7Et f 7 u/dC d d ROO Name(Print) ©© Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant ir 1. Building Oro (a)Building'Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4' 4. Mechanical(HVA(C) v,dV a 5. Fire Protection 6. Total= (1 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building,Commissioner/Inspector ofBw ings Date File#BP-2008-0435 APPLICANT/CONTACT PERSON GERALD ARCHAMBAULT ADDRESS/PHONE 171 WEST ST APT K WEST HATFIELD (413)552-7410 Q PROPERTY LOCATION 119 FLORIDA AVE MAP 32C PARCEL 151 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out 41 911-4 Fee Paid e Typeof Construction: REMOVE 10 X 6 LANDING/STEPS&CONSTRUCT 12 X 12 REAR DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 010788 3 sets of Plans/Plot Plan THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION PRESENTED: 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 Street Commsssoe Permit DPW Storm Water Ma gement 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. 119 FLORIDA AVE BP-2008-0435 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C- 151 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) CateLorv: BUILDING PERMIT Permit# BP-2008-0435 Project# JS-2008-000642 Est. Cost: $2000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: t?se_Gi-ouR: GERALD ARCHAMBAULT 010788 Lot Size(sq. ft.): 13808.52 Owner: HOULE SHAWN Zoning: URC Applicant: GERALD ARCHAMBAULT Applicant Address: Phone: Insurance: 171 WEST ST APT K (413) 552-7410 O Workers Compensation WEST HATFIELDMA01088 ISSUED ON:1012612007 0:00:00 TO PERFORM THE FOLLOWING WORK.REMOVE 10 X 6 LANDING/STEPS & CONSTRUCT 12 X 12 REAR DECK POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector tinder-ground: Service: Meter: Footings: Rough: Rough: House# Foundation: Drivc%vay Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: insulatioa: Final: Smoke: Final: CK l7i ('g-t41 S THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. _ ,�- r Certificate of Occupancy Signature: FeeTyt)e• Date Paid: Amount: Building 10/26/2007 0:00:00 $50.001622 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo