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17A-075 i • R e Gif.-�) of �QTarflIZ1111 Pf011 - _— R f �Za3a itch nrcl(n- DEPART MEI-T OP DUILDI]\,C INSPECTIOI.'S 212 Main Strcet Municipal Building Northampton, Mass. 01060 I I ti R1t1.IZ'S COi U)✓NSATION MSURACE AFFD),, j-j, ', (1;ccusxJperm;ettx) with a principal place of businessfresidence at: �S G (phone::') (so-c-cU/ci ty/staicla p) do hereby terrify, under die pains and penalties of perjury, ?hzi I O I am an employer providing the following'wor-kces coinocns-nnon covemge for In), e-luployces Woliang on ties job. I (Iiszu-:n=Corer ) (PoLic:N-u-m r_r) (r:"pir-acior,D2j--) O I am a sole proprietor, general contractor or homeowner (ci;cie one) amd have hired the couractors listed below T-rbo hive the folio%wing worker's cooptasadon pokiest (i+BSI]: 0; CO.17nci0r) (IIIR ranc0 Coinpanyillouc_ ?"tunLCr) {Zr'•JliJGQ I bate) I (Name of Coocramor) (Las-- ranee. Comoaa)vPo!im; Nuacrr) (_Laoil;:tion Date) i I I i (Name of Conrraclo;) (Lasuranc; Company/Polio- Numbu) (Expirdon Datc) (Name of Conametor) (Lnsurmcc Compaay/PoUcy Numb:r) (Expi-,6oa Date). (nt1,'Ih ..ti:-Z:oc=l eca,if nce�..:y to atc!v�tnfkxm oo pCtn-iaia6 to.11 Does-tn:z) I am a sole proprietor and bave no one working for me. ( ) I atn.a home owner performing all the work myself. i 1 NOTE:plesc be nwut ti, {]a 6emro.�ve s .�o c=plcy P_-%,=to to - c�woa c re�a .ori ov c d..ell_�of ao(tncce th a L---ter-is--Ind ttx bom.-.o=I=da oc oa the p-v�appu�theca -c w(E-M.rtty Deed.-ni to be —vior--unc c the w=;,d3 o=p=:.tioa A=(GL`t 52,=1(5)�:pptinaon by a homcoava fcr a tip_oc pcmil t>=y c,4&d t1:c )cgal m-'%-of na==Ployoc uoder dto WlkS el CompomaLioo Ac- 1—d r' d tba b. to tbo Dcq.rtm.a¢urin�atr;cl AcodcrtL-!O(Loo cr 4a�rat th. covc-z4�c veil-caioa and 0--t L•.iltac to sonar:)oven Sa tmd--sottioa 23 A or MGL 152 can Icd to tba imvozi ioa of aimiazl petunia Dona:mg of a fine orup to 5 t•500.00 andlor 6mprL�oau3 =of up to one ycr cod a Nit pm.!'ua in tSe form of a Slop W ode Ord--and a fun 0(:S 100-00 a day aptiau me For X1.1 u.e only - i - Permit Numlxr Y 1,42 P., Lot itturr of Lia=t5crlPct7ttiucc ) " 4�HAMPT , O � � � �1'iiassadZuseffs - DEPARTMENT OF BUILDING INSPECTIONS / INSPECTOR 2112 Main Street • Municipal Building ��ti yam.,r• Nordi,impton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sup<: .-i sor. T hz state defines"Homeowner" as, "Person(s) who owns a parcel on which he/she resides or intends to be, a one or two fm0y__-_- 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 r',egulations. 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 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 r SECTION 8 CONSTRUCTION SERVICES t 8.1 Licensed Construction Su ervisor, Not Applicable ❑ 2 Name of License Holder: lLicense N tuber —leg f / eew 9M / O . 110 4r Address V Expirsfion Vie Lf-OV-4ro9/S Signature Telephone S.Re``° eceil t Tome tin aavertent Ca" r - Not Applicable ❑ St34r r Company Name Regist ar tionNm r -- - Address Expira i n Date Telephone SECTION 1'0-WORKERS'COMPENSATION INSURANCE AFFIDAVIT`(M.G:L.c.452,§>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...... ❑ �V_ 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 r f _ SECTION 5-DESCRIPTION 017 PROPOSED WORK.(check all.applicable) New House Addition ❑:.: Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs J0] Decks [p Siding[E3] r Brief De_scrijal=of Propo ed �.-- Work: /i��Tr cm rwA) n �/rl,�eN !o J`'-7MXg' e!]d r "O&e d- /Qe 01at Alteration of existing bedroom Yes No Adding new bedroom Yes No . Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 5 ea at e", 6*:dx' e�A, iAS a aiIn: 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? 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 !, 19 Q rA/(/l as Owner of the subject property hereby authorize 42VIeIC4d 41,1V to act my behalf,in all afters lative to work authorized by this building permit application. g ture of Owner Date as Owner/Authorized Agent hereb)rcreclgre 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 pe_nall''es of penury. ��1 u•-G�, Print Name Signature of Owner/Agent Date Section 4. ZONING All Informat-i6h 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 f Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: 1 (volume-&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? No 0 DON'T 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 DON'T 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 Date-issued: 0 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 NO 0 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 r NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ty o£,1�Ioroampton Department s - �- 21� Main Street (�(� 'R© 100 JUL 1 5 � e�il .�ratta �j lw 2�Torth�pop MA 01060 -Phone-413-58j-124' hone 413 58.�-124 Fax 413-587-1272 PfottStt ` any I1C�''+ R p i,t i k•r �.C-',i 1;x:15 Qt�le��E;CIf�F ��'"� �� 01Pj�t• '; ,'"`'�s,:.. APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section„to be completed by5office 1.1 Property Address: C/vve f'���,ri c3 Maw Cotnit /O`G�C19 p�0 one" Overlay Disfnct Etttt St CIS JC SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT- 2.1 Owner of Record:/ Xl,ft/aC �y S Name Tint' - Current Mailing Address: shy-yc a- 1 Telephone . ature 2.2 Authorized A e t: Name(Print) • Current Mailing Address: ©9i8 Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item - - Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (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) pQ��" Check Number This SectiowFor Official Use Only Date; Building;PermitNumber.' Issued: Signature: Building Commissioner/Inspector of Buildings Date 4 CLOVERDALE ST BP-2006-0053 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-075 CITY OF NORTHAMPTON Lot: -001 Permit: Build ft Category BUILDING PERMIT Permit# BP-2006-0053 Project# ]S-2006-0068 Est. Cost: $3100.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Andrew Church 104480 Lot Size(sq.ft.): 10105.92 Owner: MEAKIM DONALD W Zoning.URA Applicant. Andrew Church AT. 4 CLOVERDALE ST Applicant Address: Phone: Insurance: 184 Spring St (413) 586-0918 FLORENCEMA01062 ISSUED ON.7115105 0:00:00 TO PERFORM THE FOLLOWING WORK.-REBUILD CHIMNEY 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 7/15/05 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo