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25C-207 (2) X LJ _IU U� W=ihalIT27fan F)EP��RTMZ_'VT OF B UILDING 2VSP5=ONS 7,7 glair.21glair. Street 0 Municipal Building N S P)_1:C TCP Nortbampton, MA 01060 ............. ryrva,ryl r-VVT7N7VID AITfNnWT,V.T)t"_TNT'FNT The State of Massachusetts allows the homeowner the riglit under 78 OCNa 108.3.4 to sa-L-- defines "Homeowner" as, "Person(s) act zis/her construction supe: _or. il.- who owns a parcel on which he/she resides or intends to be, a one or two family dweMng, attached or deached 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 who seek to use the home owner exemption, to act as their own construction superv.'sor, 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 building insi3ectioni(before work is co-neealed). insulation inspection (if reguired) and-aTinal-buildinginspection. 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 inspected. If the homeowner hires other trades to per-form work(electrical, plumbing&gas) the homeowner will be responsible to make sure that t:he 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 DEIAY the project until such time as the proper permits and inspections are made understand the above. (Home owneq/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 j-7 Wetv The Commonwealin of fassachusezrts --�— Department of Industria.t.1`2'ecidents Q j jice of Investi a.T.ions 500Wa5hin97 on Street IBoston,A 02III ww-K,.mass a Ovldia Workers' Compensation Insurance Afiidati-it: Builders/Contractors/Electricians/Plumbers ADPlicant Information Please Print Leaiblv Name on/Individual): CU rZ- f'- C-i c�' Address: ;2,2ti w ,S D City/Statz/Zip: 01'3O J Phone-ii: y' 3 -2 V L 9 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. 0 I am a general contractor and I have hired the sub-contractors 6_ ❑New construction employees(`u1.I and/or part-time). i r- T listed an ms attached shee� ( 7. Remodeling I a.T1 a so,.e proprietor or partner- ship and have no emp oy ees These sub-contractors have j g- jqZ�' Demolition working for me in any capacity. employees and have workers' � 9. ❑Building addition rNo workers' Cou�u..urSlunizCL' corop. iTic7tianCe+ required] 5. ❑ tit%e are a corporation and its 10.[�Electrical repairs or additions =_❑ I am a homeowner doing all work office s have exercised their I L Plumbing repairs or additions myself o workers'co right of exemption per MGL , � � c. 1f2, 14 , and we have no 1� []Roof repairs insurance reed.]t § ( ) ili.® Otherrr-We-Par.Tr e- at,-14 employees. [No workers' coma.insurance required.) Jrf/ G't v.-, - ---'env appii�n ca is ooz�. must a sa out the soon ae.ow snowing then•workers'comocasanon pohcy nifor�iioa T Homeowners who submit this affidavit indicating they are doing all work and then bin a outside contractors must submit a new affidavit indicating such. Contractors dizi check this box must attached an additional sheet showing the name of the sub-contactors and smote whether ornot those entities have employees. If the stb-conca=rs.bave employees,they nmist provide their workers'camp_policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job sire information. Insurance Company Name: Policy x or Self-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 rewired 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 fne 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 Investi_ations of me DLL for ins-,lance coveraze verification. I'do hereby ce under the pa&zs1aV%dpena&es of perjury that the information provided above is true and correct afzir ----- mate: Phone : vrTtczai use only- )o not n rate rn tft arcs, to be cornprered by ruy or town oJrzciaL City or To _ -- --" _ __---_ _- _-___"--Permit/License Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector S. Other Contact Person: Phone=: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: n Not Applicable ❑ Name of License Holder: LLt cL r✓) a ( d S /7 5-7 2- License Number y c.-y 6-' 0°13°11 Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ ��G:1 cl.�s �1 �r L t u 4 L �i- 73 V.11 /'p et .2 C1 Company Name Registration Number Address Expiration Date TelephoneO> 2�0 9' C 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. -Rome 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"c ifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State ocal Zpping Laws and Stat f Massachusetts General Laws Annotated. k Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors 2S Accessory Bldg. ❑ Demolition FX] New Signs [0] Decks [Q Siding [O] Other[p] Brief D caption of Proposed k � l Work: K✓"kd ° T jRe Fj'XCcf 4ttL ((2C rk;,, i ye (:1.,jeQ Cp SF Alteration of existing bedroom ke Yes No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll>(Sheet Ga. 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 S I 'E' e- vJ Spa f l e � as Owner of the subject property hereby a rize W I LC' "� 1 L to act on y[ half, iri matters la 've t oQk a thorized by this building permit application. f ZIL igna Ow er V Date I to l L-L-( CX` \ �� �' i �Ck 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 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: R: Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved - parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW Q YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q 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 0 NO IF YES, describe size, type and location: E. Will the conctructinn artivity riisturh(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. Department use only City of Northampton Status of Permit: Building Department Curb Gut/Driveway Permit 212 Main Street Sewer/Septic Availability ROOM 100 WaterNVell 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 L J rV 7 e,yu S7 Map Lot Unit A c�' h OL � CL Zone Overlay District �" i C) / C> l- C) Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print)T Current Mailing Address: i — `7/t -3 > L C. Telephone Signature 2.2 Authorized Agent: &-f , 3 y� KJ �. �l. ✓V\ y\ f 7C+X / l�I 1�C7 r'V\ l �'y ��'-`t Name(Print) Current Mailing Address: [3! 3 0 f /- 4// 3 - Z`-f `? -- -7-,-" k,i Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 5 C 0 Cl (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=11 +2-+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: - Building;Commissioner/Inspector—ofBw1 mgs °" Date I t File#BP-2008-0680 APPLICANT/CONTACT PERSON WILLIAM CHILDS ADDRESS/PHONE 132 ELM ST HATFIELD (413)247-9269 PROPERTY LOCATION 17 LINDEN ST MAP 25C PARCEL 207 001 ZONE URC 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: REMOVE&REPLACE FIRE DAMAGE&RESUPPORT SUPER STRUCTURE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 014572 3 sets of Plans/Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 Corrunission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay 2 Signature of Building Offi al Da 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-2008-0680 G1S#: 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: FIRE DAMAGE BUILDING PERMIT Permit# BP-2008-0680 Project# JS-2008-001041 Fs(. Cost: 535000.00 Fee: $175.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: WILLIAM CHILDS 014572 Lot Size(sa. ft.): 14244.12 Owner: SOITOS STEPHEN Zoning. URC Applicant: WILLIAM CHILDS AT. 17 LINDEN ST Applicant Address: Phone: Insurance: 132 ELM ST (413) 247-9269 HATFIELDMA01038 ISSUED ON:211512008 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE & REPLACE FIRE DAMAGE & RESUPPORT SUPER STRUCTURE PAST TtIIS 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 2/15/2008 0:00:00 $175.002151 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 17 LINDEN ST BP-2008-0680 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C-207 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: _Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate gory: FIRE DAMAGE BUILDING PERMIT Permit# BP-2008-0680 Project# JS-2008-001041 Est. Cost: $35000.00 Fce: $175.00 PERMISSION IS HEREBY GRANTED TO: Co_nsi. Class_:_ Contractor: License: Use Group: WILLIAM CHILDS 014572 Lot Size(sq. ft.): 14244.12 Owner: SOITOS STEPHEN Zoning: URC Applicant: WILLIAM CHILDS AT. 17 LINDEN ST Applicant Address: rnone: dnsnr...cio: 132_ELM ST_ __(413)247-9269 HATFIELDMA01038 ISSUED ON:2115120118 0:00:00 TO PERFORM THE FOLLOWING WORK.REMOVE & REPLACE FIRE DAMAGE & RESUPPORT SUPER STRUCTURE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Insl: cta;r oI'll iinibino Inspector of Wiring D.P.W. Building Inspector I?uderzroui�fl: Service: Meter: 40 l OK G 9/Z61d$lwtiI Footings: Iron%h: Rough:,]l3"'100 House# Foundation:©k Cl��y•� W/-- Driveway Final: Final: ,•�,��•� _ Rough Frame:G�{ 7 O )4✓✓ Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: L L k i in:tl: Smoke: �/�(,- I ��/ .' Fir.-A; 01V I-L/05101; 3 "PHIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate Of Occll Signature: T't'e I e'�e: _ ---•- ?ate Paid:Amount: Building 15112008 0:00:00 $175.002151 I" Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Conunissioner-Anthony Patillo i�