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32C-308 (8) �� w moo, 1 j �� 1� G �. i I�, 1 e 5 r "� i, 5 �'; n 1 1� r Y 1� i . k Y ,'1 t �. i. f �. j C �; r� � .. ! � d 't 1� f t, SHEET OF Teresa Wong Neyhart, P.E. PROJECT O f TNT Consulting f<' PRO)EcT No 16 Kosior Drive Hadley, Ma. 01035 DATE P: U i? fTT' bV(-P,'( ILit zz� -d 'j P L CD Ito " Loil(l jej Lriily of Northampton z $ «� �1'rlassaci�usetfs ; K' DEPARTMENT OF BUILDI]`G INSPECTIONS INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as l;is/her construction sups,: .-'sor. 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 rouLh 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 exera.ption) - I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location 4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s�•°•� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly .T. Name(Business/Organization/Individual): t Q 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 S. Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp. insurance.: required.] 5. F-1 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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 - -- 13.FOther employees. [No workers' comp.insurance required.] _"fcny appIi—can a c ec ox must a o i out a section a ow s owing eir 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 cri-ramal 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 file 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 un 'ns andpenAVes of perjury that the information provided above is true and correct. Si atu- Date: Phone#: Official use only. Do not write in this area,to be completed by city or town officiaL 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 0 Name License Nu ber l� o2— e 4'9� Address Expirati n Date Signatur Telephone 9.Reiiistered Home.lmpirovemerkCorifractor„ ,, _% „µm ,, Not Applicable ❑zz 74 Company Name Registration umber Address Expir i Datdf- 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...... ❑ l r.� �Ho'me,Ownelr�xeliititi`on 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 buildine 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 z � SECTION 5-DESCRIPTION OF PROPOSED`WORK(check all applicable) New House F-� Addition E-1 Replacement Windows Alteration(s) Roofing F Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[a JFJV Brief De ripttJ Pro osed Work: J 6�'�{- V'0 pt-rI4't' A (era L C /A, Afteration-of existing bedroom Yes No Adding new-bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa 1 New-house an'd oral ition.ta e;;C q iiousincf complefe-fiherfollowin : 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 will 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 I, Rlik-kN4- 'Szh-Ae--,xc, as Owner of the subject property hereby authorize u `r'<•R�-c c- to act on behalf, in all matters rel ive to work authorized by this building permit application. Signature of Owner 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 pain and penalties o perjury. Print Name c� 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 column 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 Perm t/Var nce/F i nd ing ever been issued for/on the site? ' ----- IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? �� NO �� DON . "^".= 0 .`S IF YES: enter Book Page and/or Dnnument# �� B. Does the site contain a brook, body of water orwetlands? NO �~�� DON7KNOVV �~/ YES �~� IF YES, has permit been ur need to be obtained from the Conservation Commission? Needs tobeobtained v~~� �b�a�nad �~� Dote �ssumd' ! \~� \~� ' � C. Du any signs exist nn the prnperty �� YES ��/ NO �~� IF YES, describe size, type and location: i D. Are there.any proposed ohanges-touruddt» �_ufsigns intended for the property? YES 0 NO y~~, IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre oris8 part o[o common plan that will disturb over 1acre? YE8C ) NO ��) �� |F YES,then a Northampton Storm Water Management Permit from the DPW is required. K Y a ai .,+Qepa��7gltSe o [y "ate �I CIy of NorthamptontatCJS,i3 a s BuiJcing Department :Curb ��; �� - `"'� 2�1,�J Main Street �'Ro' m 100 _ lateelt�a�ility� �' � a �` 2 LU�Nort mpt n, MA 01060 �i�. n °� 3 k,. phone 41 - r 7-12 Fax 413-587-1272 PIoSde Ptap SfnerSpec APPL10 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: }� one Overlay District Flm St.Distrsct rR Distract _ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 5 z1 �t �► �( L L v 3 S I Name(Pint) _ Current ailing Address: Telephone Slgna ure 3 2.2 Authorized Agent: Name(Print) Current Mailing Address: 0 id Signature Telephone — 7 7a1 6 SECTION 3 ESTIMATED CONSTRUCTIA COSTS- �/'�e2 r Item Estimated Cost(Dollars to be Official Use Only completed bv permit ap licant 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=(1 +2+3+4+5) Check Number This Section For Official!Use Only Date' Building Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2008-0081 APPLICANT/CONTACT PERSON Ronald Mistarka ADDRESS/PHONE 122 WEST ST WEST HATFIELD (413)575-1271 PROPERTY LOCATION 5 HENRY ST MAP 32C PARCEL 308 001 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: REPAIR FOUNDATION y New Construction Non Structural interior renovations Addition to Existing Accesso Structure Building Plans Included: Owner/Statement or License 069836 3 sets of Plans/Plot Plan THE OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO FO 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 Elm Street Commi /Z,, Signature of uilding 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. r rr ' � 1 R q x "tax E �n t f � n x t 9 a x BP-2008-0081 HENRY'ST , rI5#: OMM N' EALTH OF MASSACHUSETTS &"� 32 , , CITY OF NORTHAMPTON TER NS.CONTRACTING,WITH UNREGISTERED CONTRACTORS Pcrsnit: POt NO HAVE AOCESS TO THE GUARANTY FUND (MGL c.142A) I B I' LD sate o U ING PERMIT Feu t# SP- 0(IM09 Frfliect JS•2008-00fl $ Fst Gast•�150400(t Fe 7 5.00 PERWSSIONIS IIERES GRANTED TO: const.Clams: Contractor: Dense: Use Grew. Ronald Mistadca 062836 r nr craze( &j; 38594-16 Owner: SZAWLOWW REALTYINC Zoning:,Uxc Anvticant: Ronald Mistarka _._.- NEW:-, A nt�cant Address; 1'fi�ner Insurance. - - 122 WEST ST 4 575-1271 WEST HATFIEL.DMA01088-0519 ISSSrJF& N:7f30f To PERFORM THE FOLLORING WORK.-REPAIR FOUNDAti6N PONT THIS CARD;§Q IT IS VISIBLE F_R_.QM_,TI1kfi=XT Inspector of Plumbing Inspector of Wiring 1).P.W. Buildingl Underground: Service: Nie#er: Footings: Rough: Rough: 'Ho use 4 Foundattioa . /(j ,6 7 1-&1�1 Driveway Fhw. Final: Final: °mi nigh Frame Gas: Fire Department F yilnce Chimney: ;.. Rough: Oil: Inst> aon. Final: Smoke: s�C' THIS PERMIT MAY BE REVOKED BY THE C' OF N4R'I`I[ MP " UPON ViOLATi m r ANY OF ITS RULES AND REGULATIONS. Certificate of Og=ancv 1 r Feghye• elate Paid: Amount: Building 7/30/2407 0:00:00 $75.003173. 212 Main Street,Phone(413)587-1246,Fax:(413)587-1272 Buildhig Cc�mrnissioner-Anthony Fatillo }