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29-103 (6) y ! a<_saci�iisc { —� DEPARTMENT Or BUI DES\G LvSPB�'iiOtiS �ro ---c vl INSPECTOR 212 itilain S 0 Municipal al B uilding �> Norrhwnpton, MA 01060 YTr'VN Ar-17 rVVX7'N7ZD �cY� r7llN gf �,'�Jn�N7.F.'l(;FN(FNT lakilY1� 1 . VrIIUl♦ LLYx.irxi 1xv: ast..�... v v The State of Massachusetts allows the homeowner the right under 7800MR 108.3A to act as I:is/l��er construction sup.: -:sor. The state defines "Homeowner' as, "i erson(s) who owns a parcel on which he/she resides or intends to be, a one or two family dweHing, 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 consu action super t isC to be awaTe 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 worm at various stages, which include foundation/footings (before back-FII). sonotube holes (before Dour). a rough building inspection(before work is can-ceded-) i is-uhttion-inspection (if required) and_afn.aLbutlding.insnection. The building dep artment requires these inspections before the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occupancy_ until-tbe-work car 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 VA AV t� 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 -)0 Address of work location The Comrnonwealrit of-I�Iassachuserrs �-�-- Jepaf'�menr©�-Industria_I accidents V!{LCeofIn-VesIi azon.S is 600 Washi;r, on Street Boston, �3TL-1 02111 wivw.mass.gov/dia Workers' Compensation Insurance ffldatiit: Builders;Contractors/Eleciricians/Plumbers DDlicant.Information Please Print LeaibIv N=e (3 uiness/Organization/IndividuaI): Address: City/Sta&Zip: Phone.-: Are you an employer?Check the appropriate boar Type of project(required): ❑ a e�Ioyer with I I am 4. I am a gene-al contractor and I -�- employees(full and/or part-time). nave hired the sub-contractors 6- ❑New construction I <.-, I_a listed on the sheet T ❑R emode;ng ❑ m a sole proprietor or partner- e attac sLi~and have no enploy ees These sub-c-ontractors have S. ❑Demolition ' working for me in any capacity. employees Y es and have wormy 9- f BuiIai:z_z addition I ENO workers'co:�,.:�s-�.,:�ce comp. _*nance.* require,y] 5- [] We are a corporation and its 10.0 EIectrical repairs or additions �. I am a homeowner doing all work officers have exercised their 11.0 Plying repairs or additions myself o workers'comp- rift of exemption per MGL � c. 152, §1(4),and we have no 1 []Roof repass inatTrance required-]t 13.❑ Other employees.[-NTo workers' comp.insurance required.] ------ appiicaut MZE cnerta Dox K avast aso ED out me section oeiow snowing their work='corapensaaon policy mformatiom Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mustsubttut a new affidavit indicating such- 'Con=aCtU15 that check this box mustattached an additional shed showing the name of the sub-contractors and state whether or not those entities have employees- If the sub-contiactors.have entpioye°s,they must provide their wor:k='corrm.poli cy nurnb . I am an employer that is providing workers compensation insurance for my employees Below is the policy andjob sue information. Insurance Company Name: Policy#or Self-ins.Lic. Expiration Date: Job Site Address: City/State/Zip: Attach a cony 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 S11500-00 and/or one-year imprisonment as well as civil nenalties in the form of a STOP WORK ORDER and a Ere 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 Investi_ations of the DLA for ins-,rance coverage vermcadon. I do hereby cerdfy under thepains andpenalties ofperjuiy that the information provided above is true and correct mate. Phone r: I � v'7LC i use only_ ­0 not Ferrate to tht,;area, to be conrplewd bw ciiv ur town official _City or Town: _ __ _ -----_-__ __ ---Permit/License M Issuing Authority(circle ones: 1.Board of Health 2.Building Department City/Town CIerk 4.Ele=-kal Inspector S.PIumbing Inspector 6.Other Contact Person: Phone T: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9 Registered Horne Improvement Contractor: Not Applicable ❑ Company Name 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...... ❑ 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 he 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 A,4,1 1) t SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [❑ Siding [O] Other[[D] rief Description of Proposed Work: 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? i I 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 all matters relative to work authorized by this building permit application. Signature of Owner Date I, ?( 'Wi ' 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. Print Name (� Signature of Owner/Agent Date M ' t r 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: _,U Rear Building Height Bldg. Square Footage Open Space Footage % _. ._. (Lot area minus bldg&paved narking) #of Parking Spaces Fill: (volume&Location) _v ._..._ ------ . A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW /� 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 YES 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 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 NO AU IF YES, describe size, type and location: E. Will the construction activity disturh(clearing, grading, excavation, or filling)over 1 acre or is it part of a common p-lan 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 ijans phone 413-587-1240 Fax 413-587-1272 PloUSfte,Plans Other Specify` APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR'TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 9 si,) Z�-Jfrtj - Map Lot Unit l Zone Overlay District U I U It/ Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone hone 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 com feted 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 Building ermit Number: Irate g Issued: Signature: Building Commissioner/Inspector ofBw ings Date BP-2008-0654 Gls #: 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 heI-n,it# BP-2008-0654 Project# JS-2008-000998 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 31450.32 Owner: PRATT ANN C Zoning: URA Applicant: PRATT ANN C AT. 454 RYAN RD Applicant Address: Phone: Insurance: 5 BLACKBERRY LANE (413) 341-3278 O NORTHAM PTONMA01 060 ISSUED ON:112312008 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL PELLET STOVE 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 1/23/2008 0:00:00 $25.00312 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo