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32C-302 (5) GEP.°_RTM NT OF BUIZ.DD7 C- ItiSPE=- ONS �CTCK '=I?Main Stre�i Municipal Building NSP 01y Northampton, MA 0I060 -EIR TTrN L1V11i U r1.Li\ X-v1 ii 1 . _ ., ass The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act ass i-.is l.er construction sup,.: : ;or. The stare defines "Homeowner" as, "Ilerson(s) who owns a parcel on which he/she resides or intends to be, a one or two family welling, 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 I 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 construction .`,^u'pe:Z: ; 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). sonotube holes (before pour) a rough buildine inspection (before work is can-cealed) hisnlation inspection (if reu.uired)and_aTT=a1_huil4ina.insnectio.n. 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.insae.�- Ifthe 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 signatur a requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. y Date Address of work Iocation 77ze Commonwealih of Alassachusetcs (A!-- y, Department of lndustria1-4 ccidents Oice ofInvestigarions 600 Tf'ashinoton Streer Boston,4 02111 www.mass.gov/dia Workers" Compensation Insurance a-ffidavit: Builders/Contractors/EIectricians/Plumbers ADDlicant Information Please Print Legibly e Nazne(Business/Organization/Individual): Address: Gi .)1 S4— City/State,/Zip: C v Phone., L/ Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4• ❑ I am a general contractor and I employees(full and/or part-time)_* have hired the sub-contractors 6_ -New construction I 2-❑ ,_� listed on the attached shee* 7. r1 Remodeling 1 a sore rroprietor or partner- --- I shims �� y These sub-contractors have D ship .and have no_ �e=Tees 8_ ❑�,emo,ruon working for me,in any capacity. employees and have workers 9. ❑Building addition f [No workers'comp.insurance camp.msirance.= required] 5. ❑ We are a corporation and its 10.❑Electrical revain or additions _❑ I am a homeowner doing all work o racers have exerLtheir 11.❑] lumbing repairs or additions myself [No workers'comp. right of exemption 12. 00f repairs ins rrance required.]t c. 152, §1(4),and employees. [No w1'-❑ Other comp.in�rrrance re ffppiIcant mazanenz oox r. angst a.-so nil oat me section oeiow snowing their wotle°s'cornpensanon poucv information. — --- Homeowners who submit this affidavit indicating thev are doine all wont and then hire outside contractors must subffit a new atndavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and stare whether ornot those entities have evpioyees. If the srb-contractors have employes;they must provide their work=s'comp.policy number I am an employer that isprovidan-workers'compensation insurance for my employees Below is the poEcy andjob site tnformadon. Insurance Company Name: ��V1& ei r r S Policy#or Self-ins. Lic. i Expiration Date: — Job Site Address: VCl 1-C – . h Citv'State/Zip: 'S Attach a copy of the workers' compensation policy declaration pave(s owing the policy number and expiration date). Failure to secure coverage as required under Section 2fA of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S I 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 Investisations of the DLk for insurance coverage verification. I do hereby cerztfy under the pains and penalties of perjury that the information provided above is true and earrect Date: Phone=: LOt e ottiy. vo not wrzte m this area,to be completed by eiry or town offeiaL _wn: _. _Per-mitlLicense Authority(circle one): f Health 2.Building Department 3. City/Town Clerk 4.Elect-rical Inspector S.PIun7bing Inspector rson: Phone T- SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ r Name of License Holder: , b' !� ( v 3� 9 Lic— ensNumber Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ CompanylName Registration Number Address 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 buiidine 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 EZ Or Doors r7 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[0] Brief D tion f P�[4�osed , Work­- 1 1\ r\ �1na t� V'�! ©'1nt I .v.i�—�— b ir1 Qj;C �Y Alteration of existing bedroom Yes No Adding new bedroom Yes Nn 3� Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a. 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 I 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' as Owner of the subject property hereby authorize to act on my behalf, in atters relative to work authorized by this building permit application. Signature of Own Date } © �� 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. t _p o Print Name, Signature of Owner/ gent 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 Setbacks Front 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 0 DONT KNOW Q YES Q 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 0 DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 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 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity tti,;tnrh(claaring, grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO Q IF YES,then a Northampton Storm Water Managment Permit from the DPW is required. Department use only n! of Northampton Status of Permit: _-06ilding Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability APR 15 2008 `Room 100 Water/Well Availability Nortrampton, MA 01060 Two Sets of Structural Plans plaor�e 41.3587- 240 Fax 413-587-1272 Plot/Site Plans o Other Specify APPLICATION 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: Map Lot Unit CO-'q_ Zone Overlay District Elm St District CB District [SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: t �j 1 W \ 1 Y O �i' `j1 \� 0' \ e V4 Name(Print) Current Mailing Address: Telephone Signatu e 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) 5. Fire Protection _ 6.Total=11 ±2 3_±4±5� - Check Number -- - _This Section For Official Use Only Date Building Permit Number: Issued: Signature: —— -- — --------- 6s; --- Building Commissioner/InspectorofBuifdmgs Date BP-2008-0894 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: BUILDING PERMIT Permit# BP-2008-0894 Project# JS-2008-001354 Est. Cost: $2685.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: BOB THIBODO ROOFING & SIDING 152172 Lot Size(sq. ft.): 6490.44 Owner: WILKINS-CARMODY DONNA Zoning: URC Applicant: BOB THIBODO ROOFING & SIDING AT. 17 VALLEY ST Applicant Address: Phone: Insurance: P O BOX 201 (413) 527-7663 O NORTHAMPTONMA01061 ISSUED ON:411512008 0:00:00 TO PERFORM THE FOLLOWING WORK.-ROOF OVER 1 LAYER REAR MAIN 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 4/15/2008 0:00:00 $25.003 3152 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo