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17C-194 DEPT RTMENT OF BUILDIXG INSPECTIONS �CTCR '-12 Main Strut 0 Munic pal Building INS ,,1-- E �iorthampton, MA 01060 HOME OWNER I-EA.-JE-MUPTION ACK-NOWLEDGEMENT F f Massachusetts allows the homeowner the right under 780CMR 108.3.4 to er construction sup,.- :sor. The state defines "Homeowner" as, "P erson(s) a parcel on which he/she resides or intends to be, a one or two family tached 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 I home owner." The building--department for the City of Northampton wants any per sons)who seek to use the home owner exemption, to act as their own const ucticn supe:�: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/footings (before back-filI). sonotube holes (before pour) a rough buiIdine,insaection (before work is _concealed) insulation insi)ection.(if required)and_a_final_building.inspection. The building department requires these inspec`ions before the work is concealed, failure to secure these insaections can result in failure to obtain a certificate of occupancy until-the-work can-be-inspectPd_. 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, 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 x°4 77ze Commonwealth of%Llassachusetts r. � Deparrment of Industiial A ccidents Ig .`—i=' Oy�ce of Investiganions I .F,SfY 600 Washington Streer Boston,314 0 111 www.mass.govI L a Workers Compensation Insurance AffidaNit: Builders,lContractors/Electricians/Plumbers DPlicant Information Please Print Legibly Name(Business/(Drganization/ladividual): Address: q ��-��, City/State/Zip: lj,,, .e.-., L tom.. O t _�y I Phone..`: 't 17 S'_ Are you an employer?Check the appropriate box: Type of project(required): 4. I am a QeaeraI contractor and I 1.Q I am a employer with � 6. ❑New construction mpiovees(full and/or part-time).* have hn ed the sub-contractors 1 T- sole an the a*ac?ed shee� 7. Re., TQ f am a sole proprietor or partner- ling skip a--d have no e=1oyees These sub-con=actors have T I 8. Q Lzmou�an working for me in any capacity. employees and have work--m i pro wormers'cow,:a�'Ii sruance comp.insdtrance.* i 9- Q Building addition 1 required.] d. Q We are a corpora+don and its 1O.Q Elect-;caI repairs or additions �-❑ I am a homeowner doing all work oficers have exercised their l 1.Q Plumbing repairs or additions myself. [No work_-n'comp. right of exemption per MGL 12-Q Roof repairs insurance required.]t c. 152, §1(4),and we have no employes.[No workers' 1j-❑ other comp.in.c ance required_] - ---'*Ki*v!V-PlIcant mat cnecics Doxrl niust aso ED out the section oeiow snowing their work—°-s'compensation policy information. Hotneowne s who subrint this affidavit indicating they are doing all work and they hire outside contractors must submit a new affidavit indicating such. *Contractors dial check this box must attached an additional sheet showing,the name of the sub-contractors and state whether ornot those=titles have employees. If the sib-contractors have employers,they:rust provide their workers'comp.policy number. 'am an employer that isprovidin;workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.m: 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 S I�00-00 an6'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 Iavestizations of the DL4 for ins-,�ance coverage verincation. I do hereby cent jj under thepain dpenakies ofperjury that the information provided above is true and correct Date: C) - Phone 1 [6. cuu use only. ua not write rn thzs area, to be completed by city or town offzciaL or Town: - _----_-Per-mitlLicense ng Authority(circle one): ard of Health 2.Building Department City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector her ct Person: Phone.-: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: �-- ( Not Applicable ❑ Name of License Holder: n n License Number Address Expiration Date Signature Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number Address P 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-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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement W" dows Alteration(s) F;71 Roofing ❑ �{ Or Doors 0 E Accessory Bldg. ❑ Demolition New Signs [0] Decks [Q Siding [O] Other[p] Brief Description f Proposed 1 / (, Work: i/'-',��e t of wL.L t 4.`. fLJ�„�_ 0� 'A "' EjJti , Alteration of existing bedroom Yes L�No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes lr� 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? In. 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-0 ER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGE OR'CON RACTOR PPLIES FOR'BUILDING PERMIT as Owner of the subject property hereby authorize AJ-Ci to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date k'ts t-j ,lC� -J' , 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: L:. . ..... R: . Rear ..............._..... Building Height Bldg.Square Footage Open Space Footage (Lot area minus bldg&paved - oarking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 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 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Date Issued: C. Do any signs exist on the property? YES 0 NO Q 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 Q 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 0 NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. \� Department use only `tiity of Northampton Status of Permit: ` 3ilding Department Curb Gut(Driveivay Permit 212 'v' Street Sewer/Septic Availability R om 100 Water/Well Availability on, MA 01060 Two Sets of Structural Plans ph6je 4-j3= 87-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLIGtr TION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: Map Lot Unit r— W Zone Overlay District Elm St District CB District [SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: _ Name(Pn Current Mailing Address: r S G / •y ' -3 r T, / "W Telephone Lill O b ` Signature 2.2 Authorized Agent: Name(Print) ,, A Current Mailing Address: ( g( I - s:�-�-- 3:�g r Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building v (a)Building Permit Fee 2. Electrical rte © (b)Estimated Total Cost of f 1 Construction from 6 3. Plumbing Building Permit Fee tit Dc)• D 4. Mechanical(HVAC) 5. Fire Protection Ott 0. Tu(aI-0 1 2 1 3 1 4 1 5) ( t7 L) (.hark NrimhPr This Section For Official Use Only Date. Building Permit Number: Issued: Signature: Date Building Commissioner/]nspectorofBui�dmgs File#BP-2008-0382 APPLICANT/CONTACT PERSON ANDREW T WALSH JR ADDRESS/PHONE 2 SUMMER ST EASTHAMPTON (413)522-7795 Q PROPERTY LOCATION 20 WILDER PL MAP 17C PARCEL 194 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid Typeof Construction: MINOR DEMO,REPLACE 1 WINDOW,KITCHEN RENO,NEW CABINETS,PLBG& ELEC UPGRADE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 082029 3 sets of Plans/Plot Plan THE FOLLOWING 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 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-2008-0382 GIs #: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: 1001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category BUILDING PERMIT Permit# BP-2008-0382 Project# JS-2008-000559 Est. Cost: $11000.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: ANDREW T WALSH JR 082029 Lot Size(sa. ft.): 5967.72 Owner: NORRIS SCOTT A Zoning:URB Applicant: ANDREW T WALSH JR AT. 20 WILDER PL Applicant Address: Phone: Insurance: 2 SUMMER ST (413) 522-7795o EASTHAMPTONMA01027 ISSUED ON.1011012007 0:00:00 TO PERFORM THE FOLLOWING WORK.-MINOR DEMO, REPLACE 1 WINDOW,KITCHEN RENO,NEW CABINETS,PLBG & ELEC UPGRADE 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 10/10/2007 0:00:00 $55.001416 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo