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25C-144 (4) Av 10 cl Aj- '7� N OF BUILZ)11�C- L2N7SF_';=0-NIS 212Main &rtt:1 0 Municipal Building NSP ECTOP Nortbampton, MA 01060 'rTrNI%X-17 r'%1171T'VD The State of Massachusetts allows the homeowner the right under 780C Na 108.3.4 to State C act 0_ ct as Ihlf/her construction SIIIP�.' ­-or- Tre stare defines "Homeowner" as, "Person(s) who owns a parcel on which he/she resides or intends to be, a one or two family dwelling, attached or dettached 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 bui ding-department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their own construction supervis-or, 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 E)our) a rough buildine inspection (before work is cancealSd). insulation-inspection-(if required) and-aTinal-building insnection. The building department requires these inspections before the work is concealed, failure to secure these I inspections can result in failure to obtain a certificate of occul3ancv until Ai-e work can be insaected. If the homeowner hires other trades to per form 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 ,-.P fm 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 L 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 Commonweakh oj'Afassachuse.-ts -- JeBa, ert of Indus`;ia1:4 ccidents ©nice of InVestigasioyzs 600 Y,,_ashino`,,on Street C. Boston,AL-4 02111 www.rnass.a ov/dia Workers' Compensation Insurance ffiida-dt: Builders"Contractors/Electricians/Plumbers ADDlicant Information Please Print Legibly Na-Me(3usiness/Org2nim on/Individual): Address: Cir✓/Stat-/Zip: Phone-. Are you an emplover?Check the appropriate box: Type of project(required): 1. er with I am a employer 4• ❑ I am a gene-al contractor and I ❑ Y 6. F7-New construction mployees(full and/or part-time).* have hired the sub-contractors !. n Remodeling � ? ,._ I am a sole proprietor or partner- listed on*?�e att=ched sheer. -2-� I ship and have no em?Ie;ees These sub-contractors have 8. ❑Demolition working for me is any capacity. employees and have workers Y P l ! 9. ❑Building addition i ! ^workers' co.0.:�, ="nce corm.i isance.+ [1,,70 required] 5- [� We are a corporation and its 10-❑Electrical repairs or additions =.❑ I am a homeowner doing aIl work officers have exercised their I L Plumbiaa repass or additions myself o workers'ca right of exemption per MGL [?`� comp. 1 .7 Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.7 Other comp.insurance required.] ..---'*fsry app loam I alai Merl=oox El must also nil out me se«aon oe:ow snowmg toes work_°-s'coznp©snon poucy information. T Homeowners who submit this afdavit indicatia-they are doinz all work and dten hire outside contractors must submit a new amdavit indicating such. Contractors tl+.a t check this box must.anncaed an additional sheet showing the name of the sub-conttamots and state whether or not those entities have e r piovees. If the sub_-oncactois have emploves,they:rust provide their wort-='comp.policy number. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job sue information. Insurance Company Name. Policy#or Self-ins.Lic.m: 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 se^are coverage,as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1 500-00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP'WORK ORDER and a f inane 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 DLA for ins sanc �e veri>icaaouL I do hereby cerdj under the p and penalti s of perjury that the information provided above is true and correct 20—Si2a�s -- -- -- - -- mate: Phone=: Qg1c=use only- ,o not x rate i*z JzL;arcs, to be conzpleied_k"AY ur town off7ciaL -City or Town: _ ------- - --- ----- -- - _.--_P--er-mit/License ff Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 3.Plumbing Inspector b. Other Contact Person: Phone ! SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable In R Name of License Holder: �' �'� <�J ( 3 1)L CI Licensee Number Address Expiration Dat Signature Telephone 9 Registered Home Improvement Contractor: Not Applicable ❑ � , _C � Company Name Registration Number Address Expirat— ia C �.� '� �A .,�a- Telephone (cal i fir!• C'7{�, 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. - Horne 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 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement win glows Alteration(s) Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition New Signs [ED] Decks [Q Siding [p] Other[O] Brief Description of Proposed Work: Alteration of existing bedroom Yes P-_­N o Adding new bedroom Yes Nom- " Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa 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 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 -, as Owner/Authorized A WI here y declare that t e statements and information on A foregoing apple tion are trueVaNd accurate,to the best of my knowledge and belief. Si ned under the pains and penalties of perjury. Q Print Name Sign er/Agent Date l J Section 4. ZONING AU 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 oarkino #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 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 0 YES 0 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 Q 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 constr1 irrtinn nativity disturb(clearing,grading, excavation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES, then a Northampton Storrn Wafer Management Permit from the DPW is required. c r Department use only City of Northampton Status of Permit:' Building Department Curb Cut/Driveway Permit �, II T u' 212 Main Street Sewer/Septic Availability- L Room 100 Water/Well Availability No4ampton, MA 01060 Two Sets of Structural Plans M AY 2 3 plZgo&413-,587-1240 Fax 413-587-1272 Plot(Site Plans r., Other Specify °P ?PLICAT!O1NjO -q TRUC ,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 (7-t C F`C Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailinf Address: —s, 2 �. 5 c,4 Telephone Signature 2.2 Authorized Agent: N t) 00, Current Mailing Address: ignatur Telephone CTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building C` (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 Permit Number: IIsssued: Signature: Building Commissioner/Inspector ofBw ingfd'--s Date File#BP-2008-1055 APPLICANT/CONTACT PERSON R DEAN ACHESON ADDRESS/PHONE P O BOX 1052 WIL,LIAMSBURG (413)268-0246 2 r1 q , �77 PROPERTY LOCATION 37 ORCHARD ST MAP 2 5 C PARCEL 144 001 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: ENCLOSE PORCH TO CLOSET 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 FOL OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFepproved ATION PRESENTED: 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 X0 S' t8 2d 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�vho meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. BP-2008-1055 CIS#: 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 Permit# BP-2008-1055 Project# JS-2008-001562 Est. Cost: $3000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: R DEAN ACHESON 83968 Lot Size(sg. ft.): 8712.00 Owner: GETOFF SARAH B& Zoning. URB Applicant: R DEAN ACHESON AT. 37 ORCHARD ST Applicant Address: Phone: Insurance: P O BOX 1052 (413) 268-0246 WILLIAMSBURGMA01096 ISSUED ON:512812008 0:00:00 TO PERFORM THE FOLLOWING WORK.-ENCLOSE PORCH TO CLOSET 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 5/28/2008 0:00:00 $50.003033 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Conunissioner-Anthony Patillo BP-2008-1055 37 ORCHARD S'i COMMONWEALTH OF MASSACHUSETTS GIs ORCHARD Map:Block: 256- 144 CITY OF NORTHAMPTON Lot: 1310 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT` Category: Permit# BP-2008-1055 Project# JS-2008-001562 Est. Cost: $3000.00 Fee: $50.00 PERMISSION IS HR EEBY GRANTED TO: License: Const. Class_- Contractor: Use Group: R DEAN ACHESON 83968 Lot Size(sq ft.): 8712.00 Owner: GETOFF SARAH B & Applicant: R DEAN ACHESON Applicant Address: Phone: Insurance: P O BOX 1052 (413L268-0246_ WILUAMSBURGMA01096 ISSUED UN;5/2(V2008 0:00:00 TO PERFORM THE FOLLOWING WORK:ENCLOSE PORCH TO CLOSET POST THIS CARD SO IT IS VISIBLE FI�OM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector I!nder-round: Service: Meter: Footings: Rough: Rough: House# Foundation: Driveway Final: ll Final: Final: Rough Frame: � 0616(f�al L�iuu Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final:O k- THIS PERMIT MAY BE REVOKED ICY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGUL )NS. Certificate of Occu anc Signature: FeeType• Date Paid: Amount: Building 51128/2008 0:00:00 $50.003033 212 Main Sweet, 'hone(413)587-1240,Fax: (413)587-1272 Building Conunissioner-Anthony Patillo