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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 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 home owner." The building department for the City of Northampton wants any per son(s)who seek to use the home owner exemption, to act as their own construction supe:z:sc; 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 hour) a rough building insaection (before work is _can-cealed) i-asulation._Ens-uection if required)andaTnaLhggl j a.insnecti,o.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 occupancy until-the-wark 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 DEI AY the project until such time as the proper permits and inspections are made I, 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 Address of work location \ The Commonwealth of Massachusei-ts Tom— Department oflndustrial Accidents ©fiice of Investga_*ions 600 Washington Street -�zi M _ Z Boston, AL4 02111 www.m ass.Z5 dig R%orkers'Compensation Insurance AffidaNit: Builders/Contractors/Electricians/Plumbers Applicant Information /�\\ Please Print -_Leibly ` Name (3-asmess/Orz=zation/indIvidual). \1 Address: City/State/Zip: Phone.. 11 2.'Are you an employer?Check the appropriate box: Type of project(required): 4. I am a gene-al contractor and I 1.❑ I am a employer with � 6. ❑New construction i0, es(full and/or part-time).* have hired the sub-contractors ,_,.�/I I am a sole proprietor or partner- listed on tiie attached sleet + ?- �emode;rQ „ These sub-conL-actors have Demolition I shims and have no �Ie,T.,..s �- ❑ working for me in an capac employees and have workers' � ❑ a addition y 9. Building_ [No workers'comp.his=nre C0=.instu-a.nce.++ i required.] 5. ❑ we are a corporation and its 10.(]Electrical repairs or additions 3.❑ I am a homeovmer doing all work officers have exercised their 11_❑Plumbing repairs or additions myself o workers'co right of exemption per 1VIGL y � �� 152, 1(4), and we have no 12.[2 Roof repairs c. insurance required.]fi § 13.0 Other employees. [No workers' comp.insurance required.] - --*ttriy appiican ca DOZ�. narst also out me scuoa oetaw snowm=thew workers'can-pensation policy information- Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating,such. tContncto,s that check this box must-attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have eupioyees. If the sub-contractors have employ=,they must provide their workars'comp.policy n umber. I am an employer that is provi4*,;workers compensation insurance for my employees Below is the policy and job sue informazion. 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 pace(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 DL4 for insurance coverage verification. I do hereby gear ur er d airs es of perjury that the inforrnarion provided above is true and correct ------- - Si��iii =__ — -- Date: CSe,�.. 1 t.� ?�ar2► Phone f: _'X.606-024L 37t 16 V48 vjftcuu use only. Do not write in this area,to be completed by city or town official City or Town: Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 3.PIumbing Inspector 6. Other Contact Person: Phone : SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: r'p+,� 0+ " # License NumbTIQ ii�� 1h1#�e,�v� } b O Address Expira on Da Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ 05760t Company Name (� `- Registration Number Address "qr0.(.94W* sol%2 r +,C"ri.�+/ir Expiration D e fie► `� b � il`13�t'tt'Wa � . �!tiM� a one 3 71-CYCA 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 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 0 1 E7 P Accessory Bldg. ❑ Demolition ❑ New Signs [0] t Decks [211" Siding[p] Other[o] Brief Desfription of Proposed tom... Work: ya t w_ '��5 r mow. a'1o+�'l t!^iw#X Alteration of existing bedroom Yes No Adding new bedroom Yes IP—"No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll 7.,rSheet 6a. if New house`and'or additon'to ex4 I sthielh ousing, complete the following: a. Use of building : One,Family, Two Family Other b. Number of rooms in each family unit: N>Jbe[of Bathrooms c. Is there a garage attached? s 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 Owne6of the subject property hereby authorize 2a4w to ac on my behalf, in all matters relative to work authorized by this building permit application. P Signature of Ow er Date I, s ETC. , as Owner/Authorized 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 Signature of Own Age 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 Frontageu._, .. _ . . . ._.. Setbacks Front t l� Side L. R: t. '.x.-"'' 1- L . ,�_. _ R Rear .. . Building Height Bldg. Square Footage Open Space Footage _.. % - (Lot area minus bldg&paved Harkin ) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES 0 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 DONT KNOW Q YES 0 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 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 1 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 O NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. DJ°" D epartment use only qty of Northampton statusof Permit. '' 'ilding Department Curb Cut/Driveway Per'mrt 12 Main Street Sewer/Septic Availability . J-587- oom 100 WateeJlNeil Ruallatiifity Q�� 3 pton, MA 01060 Two Sets of Structural'Plans 240 Fax 413-587-1272 Plot/Site Plans Other''Specify APo^' A N 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 Map Lot Unit ',0&0et 1Narvvhl�- G 1 OfpO Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: trs0 � C�G A. Name(Printy� Curren M ling A rig, �^ 6 /f/� Telephone Signature .� 2.22 Authorized Agent: Name(Pri turrent Mailing Address: �413) Y Zq I3 `f Signature Teleph e SECTION 3-ESTIMATED CONSTRUCTION'COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by errnit applicant 1. Building ©�U (6)'Building'Permit'Fee 2. Electrical (b) Estimated Total Cost of Q OC2,0 Construction from 6 c3 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) b w Check Number This Section For Official Use Only Date Building Permit Number: issued: Signature: Building Commissioner/InspectordiBw mg—"fd" s Date File#BP-2008-0433 APPLICANT/CONTACT PERSON R DEAN ACHESON ADDRESS/PHONE P O BOX 1052 WILLIAMSBURG (413)268-0246 PROPERTY LOCATION 390 BRIDGE ST MAP 25A PARCEL 061 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildinlz Permit Filled out Fee Paid Typeof Construction: CONSTRUCT 2ND FLR FIRE ESCAPE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 83968 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO,WATION 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 Commission Permit DPW Storm Water Management xD cry' 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. X"y BP-2008-0433 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:Non structural interior renovations BUILDING PERMIT Permit# BP-2008-0433 Project# JS-2008-000640 Est. Cost: $8000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: R DEAN ACHESON 83968 Lot Size(sq. ft.): 12196.80 Owner: KENSICK HELEN Zoning: URB Applicant: R DEAN ACHESON AT. 390 BRIDGE ST Applicant Address: Phone: Insurance: P O BOX 1052 (413) 268-0246 WILLIAMSBURGMA01096 ISSUED ON:10/26/20070:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 2ND FLR FIRE ESCAPE 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 10/26/2007 0:00:00 $50.00130871 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 390 BRIDGE ST BP-2008-0433 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25A-061 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: Non structural interior renovations BUILDING PERMIT Pemut# BP-2008-0433 Project# JS-2008-000640 Est. Cost: $8000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: R DEAN ACHESON 83968 Lot Size(sq.ft.): 1 2196.80 Owner: KENSICK HELEN Zoning: URB Applicant: R DEAN ACHESON A T: 390 BRIDGE ST Applicant Address: _.—_— Phone: P O BOX 1052 (4 13) 268-0246 WILLIAMSBURGMA01096 ISSUED ON.10/26/20070:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT 2ND FLR FIRE ESCAPE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground- Service: Meter: Footings: h164 2 5 0/S 5°✓r'G�� Rough: Rough: House# Foundation: iev�a Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: O J 'J IGj•d$ �� THIS PERMIT MAY BE REVOKED BY THE CIX Oy NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGU NS Certificate of Occupancy Si nature: FeeType• Date aid: Amount: Building 10/26/2007 0:00:00 $50.00130871 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Bui 7!t.g Conuuissioner-Anthony patilic