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25C-024 12/13/2006 20:35 4133238929 RYAN SUiLlKS rtatat nt n r J� = a Q I � � Q Q 6� i 1 i f � 1 t cl O¢��MpT0 ti$ Grif-p of Warthamptan T 111844 AChli4ttt4 - cwM DEPARTMENT OF BUILDDTG 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 nis/her construction sup,:: .,ii 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 fancily 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 rough 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, ! �� t-SON 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 ofMassachusetts Department of Industrial Accidents Office of Investigations a 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):x V_C— (TH P Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate bog: 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. F-1 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.insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.5'I am a homeowner doing all work officers have exercised their 11.E]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 G>K employees. [No workers' 13.3 Other JE comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their 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. xContractors 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. Lie.#: 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 cerrti)y under the pains and penalties of perjury that the information provided above is true and correct Sienatare: ��.c�-B'� l�' Date: (2l 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#: Q 7:Z 3 LD Q < 0 1 Z0 39Vd Sd3Q-linE NVAN F7PPP7PC rn 4-1 o 00 ZO 39Vd qAqnlTnq wwA)4 C7COC7CCTf rC'n7 Ckmn7 Iry 17r Keith&Amy Wilson—20 Northern Avenue,Northampton, MA 01060 Existing Rear Entrance IPI 11w r � s t 4 �t x C.-A c - U 5' fflI4 iY 4x.3 SO ; 2clx IQ, It3-zo L—fj� 0 TO: CITIMORTGAGE, INC. & CONNECTICUT ATTORNEYS TITLE INSURANCE COMPANY TO THE BEST OF MY INFORMATION, KNOWLEDGE AND BELIEF 1 HEREBY REPORT THAT I HAVE EXAMINED THE PREMISES AND BASED ON EXISTING MONUMENTATION ALL VISIBLE EASEMENTS, ENCROACHMENTS AND BUILDINGS ARE LOCATED ON THE GROUND AS SHOWN AND THAT THE BUILDINGS ARE ENTIRELY WITHIN THE LOT LINES, EXCEPT AS NOTED. I FURTHER REPORT THAT THE PROPERTY IS NOT LOCATED WITHIN A FLOOD PRONE AREA AS SHOWN ON FEDERAL FLOOD INSURANCE MAPS FOR COMMUNITY # 250167 r� —NOTE- ( ..•••�,.•-•,•,�_�'K� .�� , rL2�t,. THIS PLAT FOR MORTGAGE LOAN PURPOSES ONLY SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Registered Home 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...... ❑ 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,t&-IL Stat and Local Zon' g Laws an 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 E] Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[tom] Other[a Brief Description of Proposed Work: Construct new Rear-Entry Deck over existing concrete steps Alteration of existing bedroom Yes X No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes x 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? 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 I, 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, EO ITM 1 W 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. Sig ed under the pains and naltie of perjury. J4EII'M P . 1,; iLS(5KJ Print e 1 z- 1 106 Signature of Owner/Agent Date -p9i!nbai s!MdU 941 w04 1!uL9d 1uaw96euey4 JOIBM uLO1S uoldwe4IJON a u9U1'S3A 31 OON ® S3A 69joe �JOAO ganls!p 11!M legl ueld uowwoo a;o}red 1!s!jo One nano(6u!pg jo 'uo!jeAeoxa tuipeA tupeap)gmis!p A1!n!pe uo!1onjlsuo0 944 pm '3 :uol3e:)ol pue ads l `azls aqu:)sap `S3A 31 (D ON ® S3A Z Aliadoid a4;Jo;papualu!SUMS;0 suot3!ppe JO 01 sabuega pasodoad Aue aaagl aad U :u0l1e:)01 pue ads j `azis aqu0sap `S3A 31 OON O SR Zfilaadad ay1 uO 1slxa suds Aue oU 3 :panssl ale(] ® paulelg0 © paulelgo aq o;SPOON iuoissiwwo3 uoilen.lasuo3 a4; wa;paulelgo aq of paau ao uaaq 11wiad a se4 `S3A 31 ® S3A Q MONK INOU 0 ON ispue1lam jo aalenn;o Apoq `>oaq a uleluoa alts a41 saoU •g #luawnOoa jo/pue aged No09 Jalua :SU 31 ® S3A O MON)f INOU ® ON ispaaU;o tilsl8ab a4;le papao0aJ ;!waad a4;seM :S3A dl :panssl alep `S3A 31 ® S3A 0 MONA INOU ® ON falls a4; uo/.lo;panss! uaaq Jana 5ulpu!3/a0ueueA/1lwJad lelOadS a seH d (uoneaai V awnlon) �IIld saae S uplmd3o# ( mx,e 97L 19801 S•ZL 19801 panEd V Oplq snu!w ea,e to j) % a2eloo j oosdS uodO £ZI Ot81 % £•ZT Otb81 a3slooj aisnbS•$plg 0£ 0£ 1013l-1$uippe 98 S8 ma21 Z:d Zt ''I Z",d ZI :,I aP!S 81 81 1uoa3 sjaeglaS OS OS a U1uoaA 00091 0009I azlS 10 i ;uawuedoo Ouippq Aq u!pall3 aq of—I-siq.L OuluoZ,(q paambag pasodoad sui1s!x3 uollew,olul alaidwoaul of an(]paluap as ueD liuuad •palaidwo:)ag;snw uollewo;ul pd 9NINOZ 17,uothaS Department use only City Of Northampton Status of Permit: Building Department Curb Cut/Ddveway Permit 212 Main Street Sewer/Septic Availability, r, Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone°413-587-1240 Fax 413-587-1272 Plot/Site 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 (� -Zc� �.dG2TNE2P1 1°Nic�l>L Map Lot Unit 1�icCc'�+-tAvHP't`r�N i MA �lafOb Zone Overlay District Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Keith P.Wilson 20 Northern Avenue 1�1o2�U q r.nPS Uri i MAr 010bCl Name(Print) Current Mailing Address: 413-585-9476 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 1,000 (a)Building Permit Fee ("0 JAI 2. Electrical (b)Estimated Total Cost of Construction from 6 1 Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) 1,000 1 Check Number f �d This Section For Official Use Only Building ermit Number: Date g Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2007-0657 APPLICANT/CONTACT PERSON WILSON KEITH P&AMY L ADDRESS/PHONE 20 NORTHERN AVE NORTHAMPTON ()585-9476 Q PROPERTY LOCATION 18 NORTHERN AVE MAP 25C PARCEL 024 001 ZONE URB 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: CONSTRUCT REAR ENTRY DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INRMATION 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 Co ion 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. 18 NORTHERN AVE BP-2007-0657 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C-024 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 Permit# BP-2007-0657 Project# JS-2007-000991 Est. Cost: $1000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin: Homeowner as Contractor Lot Size(sq. ft.): 5009.40 Owner: WILSON KEITH P&AMY L Zoning:URB Applicant: WILSON KEITH P & AMY L AT. 18 NORTHERN AVE Applicant Address: Phone: Insurance: 20 NORTHERN AVE O 585-9476 O NORTHAMPTONMA01060 ISSUED ON:11212007 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT REAR ENTRY DECK 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 1/2/2007 0:00:00 $50.001130 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo