Loading...
32C-158 (7) _ ! XIS 11 ,_ w ... e.., 'en. ....T..•r.mZ ..x?r+u�.rr'....rx:.,. xR.;var.v?At*er �...Y _„M +.*nm!.ntt....•m..+m�+nr.. e..s+.se�wwa.�m..w..w.r ��s _ _,.._. a k ' AUG 13 4c07 � � vs Ir r 3 "K,77,77- 7". e e §. a k D ! } y� e A 3 p 16t 47- _'N1 vp-- Am -rh ___, LEI zfy of Nozf4alliptan Z = �d75RCI+liStYY9 DEPARTMENT OF BUILDING INSPECTIONS J: INSPECTOR 212 Main Street • Municipal Building 'a Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as i:is/her construction supc: ..-7sor. 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 (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, 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 a 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone.#: 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. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. E]Demolition working for me in any capacity. employees and have workers 9. ❑Building addition [No workers' comp.insurance comp. insurance.t required.] 5. F1 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.] _.*An ya–ppl—icant that checks ox 41 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 InvestiLyations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town officiat 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 ❑ f, Name of License Holder: - 53713 License Number Ee RA CL 4htlol -7 )13/ Address Expiratio Date Signature ( Telephone 9-.Re"i-st6 om'e_Im ventent Contractor �w; ,y -; ,,,- i Not Applicable ❑ �CX L 1 -7--7 if 5-:7 Company Name Registration Number ,2 d Address Expiratio Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M.G L.c.1+52,§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...... ❑ l L `Homr Q�vn�r Egell >ptr©1 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 Wi ws Alterations) Roofing El Or Doors Accessory Bldg. ❑ Demolition New Signs [O] Decks [0 Siding [Mr--Other[a Brief Description of Propos d // j Work: i G i►I,LG� /jG' Alteration of existind bedroom Yes No Adding new-bedroom Yes No Attached Narrative Renovating unfinished basement Yes i_-�No Plans Attached Roll -Sheet sa IfrNeini house°arid or-ac(drt`ron to=existi ncihoasine�= ompfet ;fhefatlovirn : 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 o. s cons ruc ion wi i 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 UlA\ as Owner of the subject property hereby authorize 01� s v 5T t �1.Z to act on my a f, i all matte relative t work auth rized by this building4ermit application. Signature of Owner Date T' I, as Owner/Authorized Agent hereby d t the statements d n ormatifn n 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 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This colunin to be filled in by Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A Has a Special Pe it/Variance/Fi ndi been issued for/on the site? --'---- IF YES, date ` IF YES: Was the permit recorded at the Registry ofDeeds? �� 1 KNOW NO �� DON Y�� IF YES: enter Book ' Page' and/or Ducument# / t—°111 YES �� B. Does the site contain o brook, body of water orweunds? 0O K ^� DON7KNOVV �~� d IF YES, has permit been or need to be obtained from the Conservation Commission? Needs tmbeobtaioed x�\ Ob�ainad �~� Date � x�� \�� ' C. Do any signs exist on the property? YES 0 NO |FYES, 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: E. Will the construction activity disturb .grading� - or0Ung>over 1oc�nr�dpa�ofo common p�n that will d��rbover 1anm? YES NO �-� IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department etse only City of Northampton StatusofPemnit Building Department Curb f�tl`tldnvewayPemii. -42 44 212 Main Street Sewer/Sep cAV6UabrtW Room 100 water/fG-6ir aifabiC>fy , Northampton, MA 01060 -woSetsofStructuraii?tans phone 413-587-1240 Fax 413-587-1272 Plot/SitPlans !` Other Specif7r 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 A--p Map Lot Unit Zone Overlay District - 1 .Elm St.District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Ik---,G e fr' Nam Current Mailing 4ddress: `f ( Telephone Sig Lure 2.2 uthorized Agent: MA- 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 1. Building (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of 000 Construction from 6 3. Plumbing S 000 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 06?Q 6. Total=(1 +2+3+4+5) 000 Check Number This Section For O#iicialrUse Only Date Building Permit Number Issued: 9..._. Signature: I jj� Building Commissioner/Inspector of Buildings �D`. ",,Ij ate i'ill I i !e e DEPT Or"j" ,tsG iNS%'L-Ci IONS ( "tO:�lll.�'.PTO'd,"!,A 01060 File#BP-2008-0104 APPLICANT/CONTACT PERSON Anthony D'Agostino ADDRESS/PHONE 9 Fort Hill HAYDENVILLE (413)268-3117 PROPERTY LOCATION 13 KINGSLEY AVE MAP 32C PARCEL 158 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Permit Filled out Fee Paid //Mo ` Typeof Construction: REMODEL KITCHEN,ENLARGE&RENO BATH&ADD 1/2 BATH,REPLACEMENT WINDOWS& SIDING New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 053713 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INy9RMATION 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 Elm Street Co sion 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. v 4 l � a , ar ,+ Fri s� a xx, t � f a x t a s r.a .r ll, t µiv 13 KINGSLEY AVE BP-200$-014 GIs#: OF MASSACHUSETTS ap:Block:32C- 158 C��'.1'�TORTHAMPTON M Lot -001 K 1} G C '# IIIIEGISTERED CONTRACTORS Permit: ¢Llildlnc HE'QVANTY FUND (MGL c.142A) Cate o ING PERMIT ,.. . . Permit# BP-2990-0104 Proiect# �JS-200$»0166 Est.Cost: $20000,0 Fee: $50.00 , ' ' & GRANTED TO: Const. Class: Cat� ttctr: ;license: Use Groun: An# ny I 'Asrli - ._ 1 Lot Size(sq. ft.): 3920.40 ' Q0214a S Rt R W Zoning:URC Lox t Atli(�'�Sifl© -ATz—.13-K �A - -_ Applicant ieant Address: ` ` _... 9 Fort Hill HAYDENVILLEMA01039 *, TO PERFORM THE FO :f „^ �r �, , E .KITCHEN, ENLARGE & RENO BATH & ADD 1/2 BATH, REPLACEMNt', Ali` POST TIMS CARD kO I 0 3a="' Inspector of Plumbing Inspector of W r g` : "P Y, Building inspector Underground: Service: Q Footings: `s i 4TF at< &/ 2 7je 4 Ga 'G,� Ra #t @ � Rough:� /� ugh / Foundation: Final: C -1Z� -G { al: . . Rough Frame:0/�C !o fG.-o 7,d .d Gas: Fireplace/Chimney; Rough: Oil Insulation: 3 F,o P- p l Final: Finals Ok 45 THIS PERMIT MAY BE REPO D ' "" ^I RT AMPTON'UPON VIOLATION OF ANY OF ITS RULES AN REGULAi'"It31�5. Qertific!jteof-Qgc–Mp—anQy Feel e: D to P Building 8/13/2047 0:00:(I0 St1.4 ) 6 212 Main Street,Pboit,(I rtl244,'fax:(413)587-1272 Building Co nissiciner-Anthony Patillo �Y '