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17A-136 45.3 d° �r ,F , �` .` FAA ",-----..._ p•O�s+xFer'd e '` `" to 163. 75 17A•134 75.12 7 , 5 75 F� 75 312.7 �' f' F` r '�►J1f Lu i 313.7 Pie,e^r��d �"`- i� � •t'a' ,'�.�rye `,,�!',�e�l.f f� �`°� ,o�,�`�,�X�% 45 °p 75 17 AA 3 ei ,,ifxt � � pY F --�--_ 314.8 112.25 17AA37 " F` r� 56.25 / /�" / r 7 A-138 1 316.8 56,25 ` ` 56.25 ' r F 139 �= ,,.�,,r,� F , 317.9 ar` 56.25 F e� . 75 E 17AA 40 r � ¢Z1iAMp�, $� � jl�aesacl�useffs �� - n DEPARTMENT OF BUILDING INSPECTIONS / INSPECTOR 212 Main Street • Municipal Building , Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to act as his/her construction sup,.: .- :;or. 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 I, r e ty understand the above. (Home own /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 / / lo,�v loca tion 7 Cr ! ' �/— f to 'k The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone.#: 7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' insurance.$ 9. El Building addition [No workers' comp.insurance comp. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL I2.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] -"- *AnYmPprf—ca­nt Mat checks ox#1 must also till out the section below showing their workers'compensation policy information. - -- t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employee& Below is the policy and job site information. Insurance Company Name: Policy#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 required 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 five 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 certify under the pains an penalties of perjury that the information provided above is true and correct. Si ature: Date: d Phone#: FA se only. Do­not in this area,to be completed by city or town official own: Permit/License# uthority(circle one): of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector erson: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9.Re 'ecedH` Im covementCorrtractor x�_ _ z.� �„ .. Not Applicable ❑ CompanV Name Registration Number Address 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...... ❑ 1 1.Y=Home Qwner Exenpti�> The current exemption for"homeowners"was extended to include Owner-occupied DwellinEs 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 a d State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition FO ReplacementWiWindows Alteration(s) ® Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] ks rai Siding[ Other[Oj Brief Description of Pr o d Work: f !`r ©e _ _'"O� f�rr Alteration of existing bedroom Yes No Adding new-bedroom_�/Yes No Attached Narrative Renovating unfinished basement Yes _�No Plans Attached Roll -Sheet 6a-Ifi New house and or-additl6ii'to exf4ln4 6666 mite iik tt �fo[l" -i: 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? - //0- f, d. Proposed Square footage of new construction. y Q 00 Dimensions �v / e. Number of stories? f. Method of heating? Fireplaces or Wocdstoves � Number of each g. Energy Conservation Compliance. _Masscheck Energy Compliance form attached? h. Type of construction I` k i/ i. Is construction within 100 ft.of wetlands? Yes o. s construction within Yes No j. Depth of basement or cellar floor below finished grade .3 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 iPERMIT as Owner of the subject property t 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 Agent hereby declare t t the sta ements a on the foregoing�application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penaities of erjury. Print Name Date Signat a of Ow Agent ° ~ Section 4. ZONING A]I 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 JOE- Lot Size Frontage Setbacks Front 7 V25-l- Rear WV Building Height W/ Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A Has a Special Perm it/Variance/Fi ndi been issued for/on the site? DON'T =^"^` YES --- — IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES '--------� r-------'--` IF YES: enter Book i Page and/or Document#. �� �� B. Does the site contain o bnouk, body of water or wetlands? NO ��l DON7 KNOW �_� YES \�� �� IF YES, has permit been or need tnbe obtained from the Conservation Commission? Needs tobeobtained v_��~\ Obtained �~� Omte�ssumd�� ! �~� ' ' C. Do any signs exist on the property? YES 0 NO 8C7 IF YES, describe size, type and location: / | D. Are there any changes to o,additions of signs intended no k property/ YES NO IF YES, describe size, type and location: E. Will the construction activity disturb grading,excavation,or filling)over 1 acre oris it part ofo common plan that will disturb over 1 acre? YBS K > NO 07 �� /Xv |F YES,then a Northampton Storm Water Management Permit from the DPW is required. Department!A 09111 pity of Northampton Status of Pem�rt ,90ding Department GurbCu Dpuewa �ecmcmrt 21 Main Street eVker�Septtc��fa'kfabiltf}r JUG Z oom 100 tll!`ater/UFWellArrarfabrhty k � 1? rtha ton, MA 01060 Pla Fk 7-1240 Fax 413-587-1272 RIoSitet?lans �" LiCATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING -SECTION 1 -SITE INFORMATION' 1.1 Property Address: This se ti on to be completed by office ) �j"J�, Map Lot Unit Zone Overlay District /yo r1ho'Jw / Elm St District CB District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: 9 r r'd �2G Name Print) Current 'ling Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: /��irex /4 4w�e: Signature Telephone SECTION 3-ESTI TED!CO TRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building �7�Jj7< D� (a)Building Permit Fee 2. Electrical -f' �} (//(�(in (b)Estimated Total Cost of �Q p��A d (/ . G'� Construction.from 6 3. Plumbing QV, j�20 Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection Op ! c12 C/ 5 6. Total=0 +2+3+4+5) Check Number This Section For Officiai Use Only Date Building Permit Number. Issued: Signature: Building Commissioned]nspector of Buildings Date File#BP-2008-0087 APPLICANT/CONTACT PERSON HAFFMANS GREG ADDRESS/PHONE 237 CHESTNUT ST FLORENCE (413) 575-8488 Q PROPERTY LOCATION 237 CHESTNUT ST MAP 17A PARCEL 136 001 ZONE URA 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:_ADD 2ND FLR(2 BEDRMS/BATH), 1ST FLR DINING RM/LIVING RM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Co ssion Signature of Building Official OK Gd 17 1 Laut o S 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. C� FAD 1 5 yy NKU�Kpql tAqtce t-eNO15A �,Gwy •� "C6��I� o ��Nfnl s a �� 6�, I ism b �s s ofd - a2ni F1 1rL�► I'J�� 22 v 5 2cLc,ILc� G �Ld CP l9 ��/ �� C" glo brlAl)ll :';� . l t A 237 CHESTNUT ST BP-2008 J87 GIs#: _ COMMONWEALTH OF MASSACHUSE7 'S Ma :Block: 17A- 136 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142 BUILDING PE Category: I� x. T - Permit# BP-2008-0087 Project# JS-2008-000128 Est. Cost: $40000.00 Fee: $514.50 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 23478.84 Owner: HAFFMANS GREG Zoning: URA Applicant: HAFFMANS GREG AT. 237 CHESTNUT ST Applicant Address: Phone: Insurance: 237 CHESTNUT ST (413) 575-8488 FLORENCEMA01062 ISSUED ON:811712007 0:00:00 TO PERFORM THE FOLLOWING WORK.-ADD 2ND FLR (2 BEDRMS/BATH), 1 ST FLR _ INING RM/LIVING RM PC_ST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring MR) D.P.W. Building Inspector Service: �+�/ Meter: Underground: Ser ��y f�y� �0 �^V , Footings: Roug''iJ"'?.-Z)';" a�Rough:3� �p House# Foundation: y fbgyZ-'V Driveway Final: Final:8-2 Final: ✓ 0:17/' Q�� �- Rough Frame: 1•�k. �� / ,,.1� V 8 re lac&Chimne Gas: Fire Department Fi P S Rough: �'��( Oil: Insulation: o Final: p,7�p8 Smoke: ° '° Final:© 7� THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy, Si nature: FeeType• Date aid: Amount: Building 8/17/2007 0:00:00 $514.50143 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo