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29-377 (2) do TI-IT i,dl�rl Ao -io E -77- 6 J9 1-10 S"t. E4 ~ a �� � �(Ia33dC7t1ISf�9 I� UEPP?TMENT OF BUILDf.\TG 12VSPf 10NS lJ 199figy iNSPECTOP 212 Main Strut • Munic:ipd Building 1y Narth.unptnn, MA 0I060 HOME OWNER EXEMPTION ACKCNOWEEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as Lls/her construction sup Sor. TI a state defines "Homeowner" as, "P erson(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, constrac*aion 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 bacltiiIl), sonotube holes (before pour). a rough building insaection (before work is co-ncealed), insulation inspection (if reouired) and-afinal-buildina 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 occupancv 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_ y Date Address of work location ' rw�♦ w a The Commonwealth ofA assachusetts Department of Industrial Accidents Olfice of Investigations 600 Washington Street /i Boston, CIA 02111 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Name(Business/Or.�miz2hon/ladividual): 'D, C, en S t Y Fly.. ie�`aer Address: - City/State/Zip: i b 010b Phone.=: LI)3 n-06 , 4f 3,Zo Are you an employer'Check the appropriate box: Type of project(required): i.❑ I am a employer with 4. X I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 12X I am a sole proprietor or partner- listed on the attached sheet 7. Remodeling ship and have no enaplo;yees These sub-contractors have g. Demo;iLLon working for me in any capacity. employees and have workers' I [No workers' cow.ins,u--once comp.insurance.: 9. ❑Building addition required] 5_ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I 11.0 Plumbins repairs or additions myself. [No workers'comp. right of exemption per MGL 12.Q Roof repairs insurance required.]t C. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp.insurance required.] --- v app icon niat enecks oox-1 must also nil out the secnon oeiawshowinz their workers'compensation poucy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicatng such. 'Contractors that check this box must.arached an additional sheet showing the name of the sub-contractors and state whether or not those entities have ­plovees_ If the sub-contractors have employees,they must provide their workers'comp.poficy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site tnformadon. Insurance Company Name: Policy#or Self-ins.Lic. -M: 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 S 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 5250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of In vestizations of the DLA for insurance coverage verification. I do hereby certify under the a* s and penalties of perjury that the information provided above is true and correct --�onature - Q7[�=►0— ` Date: /O 4 0-7 Phone : /--1 1 ? Z9 L L� ?2_0 i 'uJIlcuu use only. Do not write cn this area, to be completed by city or town offzciaL City or Town: Permit/License n Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. Citv,/Town Clerk �.,Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone T: woasbui}seymp,mmm xed ZEZZ'996'008•t8ZZ'996'008 Z8090 D Pla!fu3•AeM uosaead Z suoianloS ani}ea{:)'saoin a$an!}eAODUI ��� b S 9 1 U 3 H $t 1 2 Y 1 9 3 SONUSVHMV .��'�` U Yv�`j-��° '� O r a l �l�S i r��� ��ac�1-� � �q'.., c�uzy �rc� v�� W. SECTION 8-CONSTRUCTION;SERVICES 8.1 Licensed Construction Supervisor: p Not Applicable ❑ Name of License Holder: @ in h l S 1 1ff 1��o r ®®-76- 3 License Number -1gci Ggf)A— IA ill RA l mA 1 Address Expirati n Dat 4! 3 2°I 6 32- O Signature U Telephone _r. x 9�Reai"ssfe�ed�Ftame-fmpFOVement.Contracfor .,5491,,_, _;x„ „- -, „,,,._��� .�.= Not Applicable ❑ Company Name Registration Number C, P-1 ft s e� I oa y Cl 8 Address L� Expiration Date �q go{�c.`� )J1�1 R1 illlem��k„ Yh.,b Telephoneyj3.2`f Lo 712-log 10� SECTION 10 WORKERS'COMPENSATION,INSURANCE_AFFIDAV[F(M:G L c--T52,§'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...... Z9 ss 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. CNIR 780. Sixth Edition Section 1083.5.1. 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. J 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 + r SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable} New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing E[01 Or Doors Accessory Bldg_ ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Oth Brief Description of Proposed 1 Work: 7, st-,ll 3 renlnc.rnewt W1nLw �r►sfigl��>7, }1tW=kl�che, (h��»e"ls Alteration of ezisfing bedrobm X Yes No Adding newtiedroom Yes "X No Attached Narrative Renovating unfinished basement Yes K No Plans Attached Roll 7 Sheet Ex 12ck A l iy t v,%Q Area /i��� 6A?5+►�� I3p �row n^• 6a_4f New-�ious�an Ora dc�fior� a.exis �na:�iousirta;caltt let6l eifa'Efavt me: 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 withil i 100 yl. 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:' TQ'BE COMPLETED°ViIHEN OWNERS:AGENT`OR CONTRACTOR APPLIES-FOR BOILDINGPERMIT as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work aut oozed by tM building permit application. 0 q rZ Si nature Owner Oat as Owner/Authorized Agent her by declare that the statemen s 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 Nam Si atur o Owner/Agent Date Section 4. ZONING All Information Mus 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 i Side L. R: L:-. - R Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved oarkine) r-- #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Fin ing ever been issued for/on the site? YES IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW ® YES 0 IF YES: enter Book Page: and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Date Issued: 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 © NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filing)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO 0 IF YES,then a Northampton Storm Water Ma agement Permit from the DPW is required. w fleparFrrreni rise only City of Northampton Stafttsoi k'erm � ' Building Department CtsrCrIDf2uewa `t?e 212 Main Street Sewer/Segtr A ilaStli Dui Y Room 100 fer/ LellA ailabErA r u nn���1 Nef h mpton, MA 01060 wo Sefsaf�tcuctctraPtans pl�bne 41 -581240 Fax 413-587-1272 PlotfSe PCans VL 3 M1 \`' APPUC No UCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SE I01sl-1 INFORMATION- This sectiorrta be completed bygfftce 1.1 Property Address: _ Ri^oo woo� 17- r 1 v Q. N[ap 1=ot Uc>fl Z"orre Oueslayr-Drsf�cir - ��orev,� MA 01062— _ 8t �isfsrct C5'. istnt� ., SECTION.2-PROPERTY'OtJ NERSHIP1AUTHORIZEDrAGEUT 2.1 Owner of Record: Name(Print) Current Nlailin a Address: Telephone Signature 2.2 Authorized Agent: 4 r I 1 oI Name(Print) Current Mailing Address: b -wb—Ae3&fk y13 1 11 ( 413zo Signature Telephone SECTION 3-ESTIMATED`CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building {s (aj Building:.Permit Fee .2 2. Electrical s ;Eb}Estimated Total Cost_of O 00 Construction-from(6) 3. Plumbing s Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 7 6. Total=(1 +2+3+4+5) O. Check Number This Section For Offic€al:Use Only - -- — — aCe D` - Building Permit Number.- Issued: Signature: Building Ccmmissienerflnspector of Buildings Date . .Ni File#BP-2008-0390 APPLICANT/CONTACT PERSON DENNIS C PITTSINGER ADDRESS/PHONE 49 BOFAT HILL RD WILLIAMSBURG (413)296-4320 PROPERTY LOCATION 5 BROOKWOOD DR MAP 29 PARCEL 377 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid T_ypeof Construction: EXPAND LIVING AREA INTO EXISTING BEDROOM REPALCEMENT WINDOWS &NEW KITCHEN CABINETS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 007513 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9FMATION 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 Commiss' r e Signature of Building Of icial 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. � 1P 8 ig b A Mrsi 4 &, 4` r �y --fir t s >t 4 y +�4W fR S}:x .e g t z r,M n" 4 v �� WOF 5 BROOKWOOD DR - BP-2008-0390 GIs#: COMMONWEALTSSACHUSETTS Map:Block:29-377 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2008-0390 Proiect# JS-2008-000573 Est. Cost: $26900.00 Fee: $130.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: DENNIS C PITTSINGER 007513 Lot Size(sa.ft.): 14897.52 Owner: SANTOS MANUEL&KATHLEEN Zoning: URA Applicant: DENNIS.0 PITTSINGER A'r- 5 BRO—OKWOOn DR Applicant Address: Phone: insure M. 49 BOFAT HILL RD (413) 296-4320 WILLIAMSBURGMA01096 ISSUED ON.10/19/2007 0:00:00 TO PERFORM THE FOLLOWING WORK.-EXPAND LIVING AREA INTO EXISTING BEDROOM, REPLACEMENT WINDOWS & NEW KITCHEN CABINETS 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,,,z//dJ/ House# Foundation: j Driveway Final: Final: �''�3 y� Final:`/ 3�D S Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Fin al: L04 I THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA N OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy nature: FeeTyne: Date Paid: Amount: Building 10/19/2007 0:00:00 $130.004956 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner Patillo t lA I IS! ,r '