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32C-243 (4) ¢�tiAMPT = c� DEPARTMENT OF BUILDD,,TG INSPECTIONS 212 Main Street • Municipal Building 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 has/her construction sup,:.: .-'.-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 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." 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 rouzh 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 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Leaibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate bog: Type of project(required): 4. 1 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 2.9 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.: 9. Building addition required.] 5. 0 We are a corporation and its 10.E] Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13 JR3 Other r,o JZ / comp. insurance required.] ✓= -�17-# 7.7--N *Any applicant that checks box#1 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. lContractors 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 Investigations 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: C/Al �y- L �h �lz = Date: e, f Phone#: '2i `/.. ] ;-z? Official use only. Do not write in this area,to be completed by city or town of-ciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: y Not Applicable ❑ Name of License Holder: �� !a w tz /� �/ >G�/ /�? lz License Number 40g T�`n �T, O�3 C2 12o i 5 ins caws` Address Expiration Brate Signature Telephone PP Not Applicable ❑ C Company Name Registration Number //1 Address Expiration Oate FJ/e2 Telephone,,/:3- 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...... ❑ il . .=Horne wrier E--enpt�ori 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 SECTION 5-DESCRIPTION OF PROPOSED WORK[check all,applicable New House ❑ Addition Replacement Windows Alteration(s) F7 Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding [0] Other 19 Brief Description of Proposed ��`»�lli 7'Ii�U ✓3.�t,��rc '.c%�' ils.,G fit'/S/ I Work: �c�/a:%/LJ ;�l�hu�' /1�',�j".+ZG��L/ '.�3v3 1v"��✓'=ot/` C�'i G/�2�' �ti/�/2��L�'c�I?l�-5✓;:FLU/���' 2�'9 ��z/ Alte a ion of existing' edroom Yes _No Adding new bedroom Yes _No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa_If New'�touse anttd or addition to existing-housing, comptefie-the foliowing: 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. 1. 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 7�r as Owner of the subject property hereby authorize �toact on m a , i II e e to work x ohrrized by this building permit application. Y ' r -' � z 42 2 Signa r of Own Date 1, A-A/�-A y T 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. "r y .r Print Name 5 A� :, Signature of Owner/Agent 4Z 61 V Date - i 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 W Side L _... — R L.�°_ R. . Rear Building Height Bldg.Square Footage Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DON-r KNOW ® YES 0 IF YES, date issued:, IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 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 0 Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, 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(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. � � � 3 Departmefttus��el�� City of Northampton Stat�tsb�errt r , t. , �tuilding Department Gurb€uIlErrreway Pemat i x r . 212 Main Street Sewer�SepttcAyailabaly 3 } Room 100 WbterNlle I AVaifabiftity NoFHiampton, MA 01060 StructwW Plans phone 413-587-1240 Fax 413-587-1272 wat�SltePtans OtherSpecrfy , APPLICATION TOXO4S-TRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be comp1 ed by Offide. 1.1 Property Address: //�/ / •�JlaL�= ST Map •. of Unit Al/1 /li/�Tir/ /y�✓� /G? Q Zone Overlay D�str�ct EIm.SL District C6 District' SECTION 2'-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: j %/2 l Div Name( Current Mailing Address: V Telephone Signatu 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 ermit 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) y 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/inspectorof Buildings Date File#BP-2007-1076 APPLICANT/CONTACT PERSON Larry Yentsch ADDRESS/PHONE P O BOX 120 LEEDS (413)584-4750 PROPERTY LOCATION 116 HAWLEY ST MAP 32C PARCEL 243 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction:_FIRE DAMAGE REPAIR,REPLACE BASEMENT WINDOWS, SISTER 2 BASEMENT CEILING JOISTS,DRYWALL&SHEETROCK REPAIR New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 048666 3 sets of Plans/Plot Plan THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Pemlit 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 fro lm Street Commission 1oa Signature of Building Official D to 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. 116 HAWLEY ST BP-2007-1076 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C-243 CPTY 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-2007-1076 Project# JS-2007-001719 Est.Cost: $11400.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Larry Yentsch 048666 Lot Size(sq. ft.): 4791.60 Owner: HEBERT PAUL E JR Zoning:URC Applicant: Larry Yentsch AT. 116 HAWLEY ST Appucaitt dress: Phone: Insurance: P O BOX 120 (413) 584-4750 LEEDSMA01053 ISSUED ON:51912007 0:00:00 TO PERFORM THE FOLLOWING WORK.-FIRE DAMAGE REPAIR, REPLACE BASEMENT WINDOWS, SISTER 2 BASEMENT CEILING JOISTS, DRYWALL & SHEETROCK REPAIR 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: 4 �� 1 Final:j_- 7 � Final: &/'Z„L% q Rough Frame: Gas: Fire Department Fireplace/Chimney: 1 Rough: Oil: - Insulation: .y Final: .D�Pv"� smoke: of �c� Final: Vic THIS PERMIT MAY BE REVOKE - BY THE CIT OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGUL IYe— si Certificate of Occupancy natu re: FeeType: Date Paid: Amount: Building 5/9/2007 0:00:00 $50.00739 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 .Building Commissioner-Anthony Patillo