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25C-104 fit'�.F�f���: � '�� .d.�� ,+��°.,�-��r•� __ `' {'"4 t""�4 "� �, :. . �j "� r ';° "` �5,,,§�'�"°�aMj g �� ��a 1„� i��'�� � r' Ll 4 V� 3 4-- 1A A 1 µ i I 9 1 s -IQ 4/4 ... 1A w::� r - 04 71 d 4tv 1 DEPARTMENT OF BUILDIXG IINSP=TIONS INSPECTOR 212 Main Str=i • Municipal Building T`�c Norrbwnpu n, MA 01060 HO IE OWNER E XEMPTIO-N ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CAZ 108.3.4 to act as his/filer construction sups -::;or. Tl., state defines "Homeowner" as, "Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family ravelling, attached or detached struct, res 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 I home owner." The building-department for the City of Northampton wants any per sons)who seek to use the hone owner exemption, to act as their own cons+,action super v so, 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/footinzs (before bacl;fill). so-notube holes (before hour) a rough building inspection (before work is _concealed-) i-a$ulation inspection (if required)and_aT al_buildina 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 occupancv until-the-work-can-be-inspect-ed. 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, �� 1"t d27'Al --understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all requii cd building inspections necessary for the building permit issued to me. Date Address of work location 2— The Commonwealth of l`Vassachusetts a.m. Department of In dustrial Accidents r' Ofr'zce oflnvesrigadons 500 Washington Street r rte',a' Boston, �l1 4 02III www.mass.govldia Workers'-Compensation Insurance Af idaNit: Builders/Contractors/Electricians/Plumbers Apaiicant Information Please Print Lesiblti )' BaMe(Business/Organization/Individual): fi Lj Al 02 AIJ City/Statt~/Zip: / ' Phone.: 5 6 -9� Are you an employer?Check the appropriate box: Type of project(required): 4. I am a gene-a.l contractor and I 1-Q I am a e�loyer with Q - 6- ❑New construction emplovees (full and/or part-time)-* have hired the sub-contractors Q- listed on*I e attached sheet. 7- Remode—ling I am a sole proprietor or parmer- These sub-contractors have D l ship and have no e�lovees S. ❑�emoo LLon worldzg for me in an ca acid. employees and have workers' Y P 9. ❑Buildmg addition [No workcn'comp.in=aance co=.insurance.-' I I r- __ reautre ] 5. Q vv e are a corporation and iJL) !0-1 J E1ecti:cal repairs or additions .fz I an a homeowner doinc all work officers have exercised the11.Q PIumbins repairs or additions myself. [N o workers' camp- right of exemption per NfG12-❑Roof repairs insurance required.] t c. 152,§1(4),and we have employee s. [tio workers' 13.[1 Other cozen.insurance required..] ---' �v j:pPlicatit Mat=ccxs cox r.aaut ago ral out me sermon oe:ow snowmo their wors.s-s'cornp=sarion.poucy information- '' Homeowners who submit this a2`ndavit iadi=a—they are doing all woe's and then hire outside contractors mustsubttut a new affidavit indic3Cn,�such. Wntrac ors that caer c this box mustaitacited an additionai sheer showing the name of the sac-contractors and state cvaed2cr or not those entities have e:mioye-..s. L°the sub-contractors-have a npiovees,t`iev must provide their worsers'comp.pokey ntmtbe:. I am an employer that a providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Co=any Name: Policy-'or Sell`-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 A,1GL c. 152 can Iead to the imposition of criminal penalties of a fine up to 51,500-00 and/or one-year=risonrneat, as weL as civ2i penalties in the form of a STOP WORK ORDER and a fee 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 DLL for insurance coverage verification. I do hereby certfy under the pains and penalties of perjury thar the information provided above is true and correct Phone vTccuu use only. ,vo not wrzte in this area, to be completed by city or town_offcia± ' _.City or 'own: -_ _.-----.__- _ _---P--ermi`iLicense m issuing Authority (circle one): I.Board of Health 2_Building Department 3. City/Town Clerk s-Elect.ic:L Inspector 5.Plumbing Inspe ctor 6. Other Contact Person: Phone 1� 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: Nut 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 Exempti©n. 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.CNIR 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 zn f r SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows [Alteration(s) ® Roofing Or Doors PQ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[a] Other[O] Brief Description of Proposed _ Work: . C Ic/S I`IVE r—t Tz 04--y NC—&— d14&1^2aTS �v Alteration of existing bedroom Yes k No Adding new bedroom Yes k No Attached Narrative Renovating unfinished basement Yes DC No Plans Attached Roll C.heC� 6a If New house and or addition to existing housing complete the following: a. Use of building : One Family X Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? j 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 1, 1444'2-7 4'2-7 A 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 pals iind penalties of perjury. Print Name Zn 2 Signature of Owner,'Ag n 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 i Lot SizeOt) 4 _ Frontage �D Setbacks Front 1 Side L: L}L R: -.` L: R: Rear Building Height Bldg. Square Footage f y� Open Space Footage2 (Lot area minus bldg&paved oarkinj) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW M 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 16) DON7 KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 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 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 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. - Department use-only i f Northampton status of Permit: ,i i g Department Curb Cut/Driveway'Permit 21• ain Street Sewer/Septic Availability mom 100 Water/WelI Availability 1 Lu Northampton, MA 01060 Two Sets of Structural Plans phone 413-r 0-124 Fax 413-587-1272 PlotlSite Plans L1! eS Other Specify- APPL1CAi'T1dN-*0-C6NSTRUCT,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 Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 7 1 r)wnar of Rarnrri• Name(Print) Current Mailin Address: Telephone Signatur ' 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 2 O ct 0 U?T (a)Building Permit Fee 2. Electncal �d FrU� (b)Estimated Total Cost of Construction from 6 3. Plumbing J6 5�-ve) Gry -- Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total= (1 +2+3+4+5) d d- _ -7ZJ— Check Number This Section For Official Use Only Date Building Permit Number: issued: Signature: Building Commissioner/Inspector ofKirdmgs Date File#BP-2008-0686 APPLICANT/CONTACT PERSON MORIN JEFFREY A& ADDRESS/PHONE 29 GRANT AVE NORTHAMPTON (413)586-3987 Q PROPERTY LOCATION 29 GRANT AVE MAP 25C PARCEL 104 001 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 Typeof Construction: RENOVATE KI CHEN,NEW CABINETS&FLOORING 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 FOKOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON VATION 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-2008-0686 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 e.142A) Category: BUILDING PERMIT Permit# BP-2008-0686 I'loicct '± JS-2008-001060 Est. Cost: $3000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 4486.68 Owner: MORIN JEFFREY A& z_on"w: UURB Applicant: MORIN JEFFREY A & AT. 29 GRANT AVE Applicant Address: Phone: Insurance: 29 GRANT AVE (413) 586-3987 O NORTHAMPTONMA01060 ISSUED ON:211212008 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENOVATE KITCHEN,NEW CABINETS & FLOORING 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: IZougli; 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 2/12/2008 0:00:00 $50.00188 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo t V .8 1 Si e -. 5��9� '�4 F 3 s✓-� a w , F i r '� � �a s �Z's•�. asp �.. ¢ -f�y �$ � '` � 2� >� f`��-: ,�' , a VI Or W-owl to gamma owl PATWO01- MT Yix I tip, r # N1- ns ` Y 3 firs` "' 'u€} y` A '«-`'q �„ .k ' ? -: � ? i - max; WA- ou i t �. �`.; ,# many ao }tea e� �,� ,� �t .,�;:"� �` .�'.Aj.° � � vs����d�'*� -�- •�'`� a fi� �pit tea -��c fi �t` �z-.;*�==�..' ",;� � .a's tvx'r�"„a. '�k""�„>vvE.. �' ' ; �•�_,��§,� t ,a f� a� ,�� ,�", "� € '�.�qv-'��6`fir` "�wr; £� a 3= } '" 29 GRANT AVE BP-2008-0686 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C- 104 CITY OF NORTHAMPTON Lot. -_00_1_ PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: _Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) CateizoEy�. BUILDING PERMIT Perinit# BP-2008-0686 Proiect# JS-2008-001060 Est. Cost: $3000.00 1,ee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: tise G�ot - Homeowner as Contractor I.ot Sized fit.): 4486.68 Owner: MORIN JEFFREY A& uRB Applicant: MORIN JEFFREY A & jT.- 29 (=RANT A\/F= _ Address: Phone: Insurance: 29 GRANT AVE (413) 586-3987 0 NORTHAMPTONMA01060 ISSUED OIV:211212008 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENOVATE KITCHEN,NEW CABINETS & FLOORING PCI4'! 'TF1lS_CARD SO IT IS VISIBLE FROM THE STREET i n.ri,ec:oi• of Plumbing Inspector of Wiring D.P.W. Building Inspector Fudergruund: Service: Meter: Footings: Rough: Rough:J/ �8 I A'� H f House# Foundation: f©J6h' Driveway Final: Film]: Final: / Rough Frame: O Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation:Qk col i/�DQ� Final: Smoke: Final: (�/'1� �'/S•d�i �'It��'f'� THIS PERIVILT MAY BE REVOKED BY TH ITY OF NORTHAMPTON UPON VIOLATION OF ANY OF IT'S RULES AND REGU IO 1te of 0,,;c pqE(- Signature: hee'hlpe: Date Paid: Amouut Building 2/12/2008 0:00:00 $50.00188 , 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo T }