The URL can be used to link to this page

16C-004 City of Northampton / Massachusetts DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building b Northampton, MA 01060 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. 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 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 r ( I, 11 CW if understand the above. (Home wner/resident's signature requesting exemption) will call to schedule all required building inspections necessary for the building permit issued to me. Date L Address of work location__ __ G' S-PX4A1(, II I I i II i I ill I II I III ills I! The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations I Congress Street, Suite 100 Boston,MA 02114-2617 www.mass.gov1did Workers' Compensation Insurance Affidavit: General Businesses ApplJont Information Please Print LegJbIv Business/Organization Name, r Address:A/ City/State/Zip: one #: Are you an employer?Check the appropriate box: Business Type(required): LO I am a employer with employees(full and/ S. E) Retail or part-tirne),* 6. RestaurdittlBar/Eating Establishment 2X_ 1 am a sole proprietor or partnership and have no 7. Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. S. 0 Non-profit (No workers'comp. insurance required] 10 We are a corporation and its officers have exercised 9. F-1 Entertainment their right of exemption per c. 152,§1(4),and we have 10.M Manufacturing no employees. [No workers'comp. insurance required]" 11.[] Health.Care 4,E3 We are a non-profit organization,staffed by volunteers, with no employees, [No,workers' comp. insurance req.] 12.0 Other *Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an orpnization should check box#1, ........... lam an employer that es providing workers'emVensallon insurancefor ray employees. Below is the policy 11(formation, Insurance Company -—------- Insurer's City/State[Zip:em Policy#or Self ins.Lic,it Expiration Date:— 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 S 1,500.00 andlor 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 cer under the pales and penalties oflierjury that the Information provided above Is trae and correct. Sianature: '-M Phone 4. 1-616 Official use only. Do not write in this area,to be completed by city or town official. City or Town:_. Permit/License 4 Issuing Authority(circle one): 1. Board of Ilealth 2. Building Department 3.Cityrrown Clerk 4,Licensing Board 5.Selectmen's Office G.Other Contact Person Phone www.mass.go0dia �I i' I I illl II ICI I �� II I II I III VIII I I III I! 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 Re�tion Number 04A JJ01Z_' eC__ Address Expiration Date l / y� 4 /�,� ? 1 �►'�� Z`1 �� f7 Telephone qX I q 7 6-i,/01 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,Stat and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature II �I I II it �l II I it I Ili III I i I II ill l �I II ill __. _ I SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors (] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding[0] Other[O] ��ZZ �� Brief Descriptj�cua gf Pro osed ?� (tLu_ ( Work: L��>'i'�Yti��/�..IZ/YL.. Alteration of existing bedroom Yes__X_No Adding new bedroom Yes )K' No Attached Narrative Renovating unfinished basement Yes 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? HD d. Proposed Square footage of new construction. Dimensions e. Number of stories? i f. Method of heating? �4-�� 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_�4 Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �(Y1 •�]�p , as Owner of the subject property hereby authorize to act o my behalf, in all matters relative t_)(work authorized by this building permit application. Sign' of Owner Date I, •��%t�� 4 J t i //"�� 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. 0G%`y PrpUNef e Signature of Owner/Agent Date II I Ii I Ii Ills II II it I II I III I ICI I III I I II __ I 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: L: 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 Qr DON'T KNOW 0 YES 0 IF YES, date issued:. IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T 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 DON'T KNOW Q YES Q 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,ex avation,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. I �I i I I i �I -- � f DepartMeflt use of+ly" _ City of Northampton Status'�of Permit: W 1.4 puilding Department Curb CutfDriwiWay Permit L. l 212 Main Street Sewer/Septic Auailabiiity' I 2 �;� Room 100 VYa1er1WellAy�ilbility '11'€ rthampton, MA 01060 T'wo Sets,of_'Structural Puns ph�41 -587-1240 Fax 413-587-1272 P.IoUSite plans Electcc, P , i n''in pectiona other Specify APPLICATION TO TRUCT,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 ' 20O �PIQ.! s— SI R-C&T Map Lot Unit v /4- �� B 2 zone Overlay District Elm St.District CB District SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 3R(9 Epe M& ji;-P tit I+ e C.) Name(Ph Cur—rent p�it�gAddress: C / T=> Telephone Signatu 2.2 Authorized Agent: q1 Aj Nam rint) Current Mailing Address: ignature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building r (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of 7x— Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total= 0 +2+3+4+5) `7 00 -- Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date i III I ill i ii �I I i i i File#BP-2015-0504 APPLICANT/CONTACT PERSON JURADO KIM I ADDRESS/PHONE 320 SPRING ST FLORENCE (917)751-9215 Q PROPERTY LOCATION 320 SPRING ST MAP 16C PARCEL 004 001 ZONE URA(100)/WSP(100) 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 BATHROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 176119 3 sets of Plans/Plot Plan THE FOL G ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 ela 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. I I I, �, I ill ,III �I I, i I i I �� II 320 SPRING ST BP-2015-0504 GIs#: COMMONWEALTH OF MASSACHUSETTS MM:Block: 16C-004 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit# BP-2015-0504 Project# JS-2015-000949 Est. Cost: $8700.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DAVID COLLINS 176119 Lot Size(sq. ft.): 36285.48 Owner: JURADO KIM I Zoning:URA(100)/WSP(100) Applicant: JURADO KIM I AT. 320 SPRING ST Applicant Address: Phone: Insurance: 320 SPRING ST (917) 751-9215 (� FLORENCEMA01062 ISSUED ON.10/30/2014 0:00:00 TO PERFORM THE FOLLOWING WORK.RENOVATE BATHROOM 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 10/30/2014 0:00:00 $55.00 212 Main Street,Phone(413)587-1240, Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner