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24A-072 (4) _ 41-211_ d Co rn �_ ` Z co v ' . @ c 0 c�i m 0- � 0 Cr g7 p tU p 0 cn tj 2 �t 10 Cn 0 Q (D C' N 0 -- 0 -NN na X CD r--------;� can a LLJ co a � ,A _ l< Cf! CD C1. W L3 0) 0 20' City of Northampton / Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building w• b Northampton, MA 01060 {sspyY y71~�fi INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. 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 h use and/or farm structures. A person who constructs more than one home in a two- year period shall of be considered a home owner." r, The building depar\the the City of Northampt/to y person(s)who seek to use the home owner exemption, their own construction to be aware that by doing so you become responsimpliance with state des and regulations. The inspection process requires thilding department be cect work at various stages, which include foundation/footin a backfill sonotube re our a rough building inspection before work is concealeA insulation ins a ion if required) and a final building inspection. The building department requi es these inspe ions before the work is concealed, failure to secure these inspections can result failure to obtain a certificate of occupancy until the work can be inspected. If the homeowner hires other trad to rform work (electrical, plumbing & gas) the homeowner will be responsible to make sure that the tr s hired secure their proper permits in conjunction to the building permit issued, and that they get th required inspections. Failure of the individual trades to secure the permits and inspections as re ire can DELAY the project until such time as the proper permits and inspections are made I, understand the above. (Home owner/reside 's signature reque ting exemption) I will call to schedule all quired building inspect ns necessary for the building permit issued to me. Date Address of work cation cx 11 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/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): o r^ n�e y �C e n e w-ct Address: 1 -59 'leu �u�� S7 City/State/Zip: MA 0/ 0'/0 Phone#: 11 6 `t 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 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. Demolition working or me in an capacity. employees and have workers' g Y P tY• 9. ❑Building addition [No workers' comp. insurance comp. msurance.T 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 11.❑ 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.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the sectionbelow showing their workers'compensation policy information. tHo meowners 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 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: Date: Phone#: �//3 - 6 9 0 SS 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: p Not Applicable £ Name of License Holder: TO r re y L S 7-37 0 L1 License Number i S� ��eu14� r Sf ; I�,h f,��� C� i �7a i -20/s Address Expiration Date Signature Telephone 9.Registered Home Impiovemen YContractor: m _ Not Applicable £ S�?reV,— '7o ere y �`yi ISO Company Name Registration Number 1ter-et,c, 1oYr2y"S Aalry" C/'m--frkc-h 9 Y1 3 O i Address Expiration Date su�"r Sf/ 1'114 OHO/©Telephone `1/7 z 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 H e.-Ownerll 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-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) Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[O) Other[�I) Brief Description of Proposed i Work: C re t)"j , c?f �11�;shYd fi "✓�afi ;� ro<>, ctn / /x�,,Jr !D` n ✓�:sc vhF 7'l Alteration of existing bedroom Yes_,No Adding new bedroom Yes _X No Attached Narrative Renovating unfinished basement >f-Yes No Plans Attached Roll -Sheet sa:1f New"house and.or':adcltlon to existina Fiouslnq complefe the"followmp: 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? Fir places or Woodstoves Number of each g. Energy Conservation Compliance._ `+ M sscheck Energy Compliance form attached? h. Type of construction i. Is construction within 10 ft. of wetland ? Y s N Is construction within 100 yr. floodplain Yes No j. Depth of basement or ellar floor below fi shed gr de k. Will building conform to the Building a d 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 all matters relative to work authorized by this building permit application. 2 Signature of Owner Date e h "o r r r y as Own r/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best oopicnawledge and belief. Signed under the pains and penalties of perjury. SC f v'e, TDr ft,1 Print Name Signature of Owner ge Date /V0 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:` ! R: - —�-- Rear --- t" Building Height t Bldg.Square Footage ` - % � Open Space Footag (Lot area minus bldg&laved parking) #of Parking Spaces Fill: (' (volume&Location) — 1 A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW Q YES Q IF YES, date issued:; I IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES Q� IF YES: enter Book ( !� �_�f Page` T and/or Document# � i B. Does the site contain a brook, body of water or wetlands? NO %C;, DONT KNOW Q YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained O Obtained Q , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O 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 Q NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. i ' [ Ity of Northampton Status ofPgrFrrtt, "e t '�s fi�a �..� w.., 3 'u IF. L wuilding Department cr `CutlDrl�zetn+a�Perrriit t � 212 Main Street SevrerlSeptic;�valrailEity i , Room 100 Wetet/yIteltiva1laulty' — 3 c'U1/$ Rf6 hampton, MA 01060 Tway S 1 trctuTal Piar�s �y _phon 240 Fax 413-587-1272 I.:!(,C r C110i1S �ltrer S SCI ' it y € al`1` �s�c ' 7 e , , .: APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE.INFORMATION 1.1 Property Address: This sectlorr to .e completed by office S O 1`�)y ✓ut,d "�zr,�wc - = Map Lot Wi U11 ,/if p 4 .� ✓`Y� Zone Overlay Disfrict C�1 0,6 D EIm St Distrlcf CB:Dlstnct SECTION 2.-PROPERTY OWNERSHIPIAUTHORIZED AGENT. 2.1 Owner of Record: X Name(Print) Curren Mailing Add e ;_T 01 0 Telephone Signature 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 UGC Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection (r'�t? c' 6. Total=(1 +2+3+4+5) 3.590 y-0 o Check Number This Section For Off icial Use'Only Building Permit Number: IDSSUed: Signature: Building Commissioner/inspector of Buildings Date NOW File#BP-2014-0923 APPLICANT/CONTACT PERSON SERENA TORRY ADDRESS/PHONE 158 PLEASANT ST PLAINFIELD (413)634-8088 PROPERTY LOCATION 50 RIDGEWOOD TER MAP 24A PARCEL 072 001 ZONE URA(100)/ 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: FINISH BASEMENT(RECREATION&LAUNDRY ROOM) New Construction Non Structural interior renovations Addition to Existing Accesso1y Structure Building Plans Included: Owner/Statement or License 078904 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ION PRESENTED: pproved 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 Commission Permit DPW Storm Water Management Lk molition eIay S1 re o u' in 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. 50 RIDGEWOOD TER BP-2014-0923 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24A-072 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2014-0923 Project# JS-2014-001592 Est. Cost: $35904.00 Fee: $215.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin SERENA TORRY 078904 Lot Size(sq. ft.): 7405.20 Owner: CHAPMAN ROSALIND&LISA WEREMEICHIK Zoning. URA(100)/ Applicant: SERENA TORRY AT. 50 RIDGEWOOD TER Applicant Address: Phone: Insurance: 158 PLEASANT ST (413) 634-8088 PLAINFIELDMA01070 ISSUED ON:31412014 0:00:00 TO PERFORM THE FOLLOWING WORK.-FINISH BASEMENT (RECREATION & LAUNDRY ROOM) 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 3/4/2014 0:00:00 $215.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner MW