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29-045 5. 7 2 i 2 m:,"m S Lr=,, E L:-ding M G 10 G -ENIJ H DAI E A 01 E R E X 4.PT The State 0--fWassachuse-tts allows the homeowner the righat under 780(---MR 108,3.-,,r to aCl a5 iii e-Cop -:SO r_ T h- star--- -'afines "Homeow-ner" as, '-erson( tends to be, a one ortwo family -L- d�w--7'1.ng, attached stru=—,res accessory ILO such us e and./or farm s--,LCL res. person who constructs more than one home I'- a two-year period shall not be considered a home owner,- The b u-,-ldi-a-z-d.e7aaitnaent- for the C i-Ly of N-Lorth�--npton V'-ants any pe.-SOE(S) 'Whi 0 seek to as I- use lie home OVmer ex-.=Mptlon' to aat - Llie:l that by doing so you become responsible for compliance with state building codes and reT2afions. The inspe--'Ion process-requir-es that the building depar tm- ent be called to iaispe--, work at various stages, -which include found2tion/footinzs (before backTUD. so-notube holes (before r)our). a rough buRding ins-oection:(before work is co-r�cealed. iiis4im-ttion in&iaectian (if reguired-)an-d-a-finall-huRding-i=ectien- ?"he b ding deparanent requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occur)ancV unt-31--the-worik C-be-Jnsz).ectzd-- L-7the homeowner hires other trades to perform work (electrical, plumbing&gas) the homeo-wnrer-will be responsible to mane sure thatt-the trades hired secure their P roper permits LZ conjunction to the building permit issued, and that they get their required inspections.Failure ol"the individual trades to secure the permits and inspections as required h permits inspections ar. e =ez-1 ca-zi RIE-ILAY the proje-I unril such time as the proper per ts and, made TI 1--derstand the above_ (Home owner/resident's signature requesting exemption) I wi-71- call to schedule all required buildL-1-C,inspect ions necessary for the building Pe='t Issued to rie. Date Address.of-wc-work------- location s Levrrr-t,�rt2rit i!s' 1nw�isii I'd_lCCid-elws a _ -. O ce of Invest.,rations 600 ff cashm t n Street Boston, 14 0 111 a wyvn.rnnss.go v/ditr Workers' Compensation Insurance Affidavit: Builders/Contra,--tors/Electricians/'Plumbers A=)rlica.nt Information 'lease Print LeQibls- Name (Business;'OrEanizationi'Individual): ��/�lr 5 ��5 JE5 6t,1 S — address: 31 5 e4va City/State/Zip: Act" -a 0/0/o3_5--Phone #: Are you an employer? Check the appropriate box: Type of project(required): j 1 I am a employer'with 4. ❑ I am a general contractor and I —� J 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors ?.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [ Remodeling t These sub-contractors have S. 17 Demolition ship and have no employees �. working for me in any capacity. employees and have workers' I 9 [❑ Building addition [No workers' comp. insurance comp. insurance.- required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions d.❑ I am officers homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152, §1(4), and we have no employees. [No workers' 13.F1 Other comp, insurance required.] *Any applicant that checks box,=1 must also fill out the section below showing their workers'compensation policy information. Ho meowners who submit this affidavit indicatin;they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Conuactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have emplovees- 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: (9 12r)AS__ L x-015 Policv F or Self-ins. Lic. n: W C, 240 — S Ito Expiration Date: 6 - 8 .- o? Job Site Address: Z3 I 01� of I'SIj.o t,t� Ate# 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 51,500.00 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 may be forwarded to the Office of Investigations of the DI_A for insurance coverage verification. I do hereby certi na.ties_ofperjuiy-that-the information provided above is trace and correct Signature: Dater Phone --0ffciraLzcse_only__Do_noLrvtite_inlhis_area to b�completed ._city or town off_rcial City or Town: /?JGi�/��a�.�%'� Permit/License ��' 21_ --- Issuing Authority (crrc / 1. Board of Health . Building Departme t 3. Cit,;!Town Clerk 4. Electrical Inspector �. Plumbing Inspector i, 6. Other l Ph Contact Person: one =: �� SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: �tE 1'N't'iN U ��' Z License Number o Address Expiration Date Sigag-Efure Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ 10 a Y 7� Company Name C Registration Number F5 az z Addre s /� / / Expiration Date Telephone-/�J� 'Z 5-6 '14a 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 buil ing 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-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 O Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [o] Other[Ell Brief Description of Proposed Q Work: R+--t4 o u4*7 — 1 111 6 ez�h1 S IMF FDUT{��I N[ Alteration of existing bedroom Yes No Adding new bedroom Yes No 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 _ c. Is there a garage attached?1_ a 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 W bOD 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 j ",o U �x to act on my behalf,Jp all matters lativ,�to work authorized by his building permit application. Signature of Owner Date U L as GA30r#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. Print Nagofo ZZ—G Signat r/Agent Date x 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 DONT KNOW 0 YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES Q 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 Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained Q Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: QN 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. Department use only City of Northampton Status of Permit: Building Department Curb Cut(Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans' OtherrSy APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLIP, 'AONI=OR'"TWO FAMILY DWELLING �,: ^ ^nr5o SECTION 1 -SITE INFORMATION j I `�` vu This section to be completed by office 1.1 Property Address: l -� /� !�'/CJ( t_,S" Map I Q l.o€ S Unit 1dr4EE. Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Nam rint) ' Current Mailing Address:/ t '� 4/ - �8 —320 Telephone Signature 2.2 Authorized Agent: U L i �� s Pl a za �d , rna Name(Pri Current Mailing Address: X13 -- 2�6-16 O6 Sign re 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=(1 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: t Building Commissioner/Inspector oBw mgs - ate File#BP-2008-0713 APPLICANT/CONTACT PERSON STEPHEN J PROULX ADDRESS/PHONE 31 CAMPUS PLAZA RD HADLEY (413)256-1606 PROPERTY LOCATION 23 PIONEER KNOLLS MAP 29 PARCEL 045 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid BuildiniZ Permit Filled out 00 dj Fee Paid Typeof Construction: RENOVATE EXISTING BATHROOM(SAME FOOTPRINT_ New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 093142 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOIjd41ATION 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 Demolition Delay Signature of Building 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. BP-2008-0713 G s#: 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) Cmcsorv: BUILDING PERMIT Permit# BP-2008-0713 Project# JS-2008-001 1 1 0 Est. Cost: $5000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: STEPHEN J PROULX 093142 Lot Sizc(sq. ft.): 11979.00 Owner: ELLERBROOK RAY A&WENDY J Zoning: URA Applicant: STEPHEN J PROULX AT. 23 PIONEER KNOLLS Applicant Address: Phone: Insurance: 31 CAMPUS PLAZA RD (413) 256-1606 WC HADLEYMA01035 ISSUED ON:212812008 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENOVATE EXISTING BATHROOM (SAME FOOTPRINT) 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: BUildin" 2/28/2008 0:00:00 $50.009527 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo