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17A-218 R IA Y, FRONT 3'G c� CL©se T L L I � C? r �L RM = �M Disc. R" i Lf ViTc.4 e.IJ L-- BAAT� E;K,\t CI�CJSei 4- P W �r.✓� IQs i TI 2C21' _.w.. ROC) a F 160 C� s r ` i HA LL 0 Oco,,v f C L t)5er a,. _iir d DEPF_RTMZNT OF BUILDD�G DIVSPEC-1102VS N S P_C TOP 2112 Main S trtet 0 Municipal E uilding NortharnpLon, MA 01060 110ME (YWNER 114 EX-ENEPTION ACICNOWLEDGEMENT 1-.L%� L A-I The State of Massachusetts allows the homeowner the rizht under 780CNIR 108.3.4 to r ,el_ act as h.!S/her construction sup-: `Sor- 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 ctur dinefling, attached or detached structures accessory to such use and/or f" structures. A person who constructs more than one home in a two-year period shall not be considered a hone owner." The building for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their OIXTI C0nStrLIcti=- superZrisor, to be aware that by doing so y ou 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 backTHID. sonotube holes (before Dour). a rough building inspection (before work is cance.-Ogd). i-asulation inspection (if reguired) and-aThial-buildin-ginspection. 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 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 understand the above. (Home owner/i4id;xi_tls' 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 /A 0 OeA � 0 10) The Commonwealth of 1Vfassachusetis - Department of Industrial_-accidents ' Oiiice of Invesziga.*ions 600 IT'ash ington Street Boston,_14 02I11 - � www.mass.g ov/dia Workers" Compensation insurance afflda`-it: Builders,'ContractorsMectricians/Plumbers kmlicant information -�— —p Please Print Lesibly ?-ame(Easiness/Orz zanon/Individual): 1,M o J Address: City/State/Zip: Phone., Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a emplo er with 4. 7 I am a general contractor and I I Y have hired the sub-contractors 6. ❑New construction employees (full and/or part-time).* r,/r n r fisted oIl*fie a*rached Slle°+ T ylr"e�odP Tnv I 2. _ 1 am a sole proprietor or partner- ship and have no errmloyees These sub-contractors have S. iemoliuon woe Q for me m an capacity. employees and have work-e s' Y P 9. ❑Building addition [No workers' comp.i=,sauce comp.insurance.' 10. Electrical r=airs or additions qui ed] 5. 7 We are a corporation and its .LI am a horaeovmer doing a.I1 work oElcers have exercised their 11. Plummbing repairs or additions myse-lf. [No workers' comp. right of exemption per 1VIGL 12.❑Roof repairs insurance required]t c. 152, §1(4),and we have no employees. [No workers' 13-D Other cc=.insurance required.] - ----"may applicaiit Mt cnerk Dom Fi mast a:so fill out me section be:ow snowing then work='cornpeosation policy miorrtmuon. t Homeowners who subrrut this affidavit indicating they are doing all work and then hire outside contractors must subm it a new Zn—davit indicating such_ :Contractors that check this box rnustaaached an additional sheet showiaa the narne of the sub-conm2ctors and state whether or not those entices have ernpiovees. If the sub-cons actors have ernpiove-s,they must provide their work='comp.poficy nuziroe:. I am an employer that is providing workers compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.r: Expiration Date: Job Site Address: City,'State/Zip: Attach a copv of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25 A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1.500.00 and/or one-year inn onment;as well as civil penalties in the form of a STOP WORK ORDER and a Lne of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Oi5ce of Investigations of the DLk for insurance coverage verification. I do hereby ce fy uR d th a' axd penalties of perjury that the information provided ab ve is true and correct — aTUre`_ /�/ -- ----— irate: Phone#: f ' vffciai use only. Lo rzot write m this area, to be completed by city or town offzciaL City or Town: —_— ____ -- _—_-- — P--ermit!License Issuing Authority(circle one): 1.Board of Health 2_Building Department 3. City/Town Clerk "..Electrical Inspector 55..Plumbing Inspector b. Other Contact Person: Phone T: s � 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 Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(6)j 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. - 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 F_� Replacement Windows Alteration(s) Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition I F New Signs [0] Decks [❑ Siding [O] Other[[3] Brief D scngtion of Proposed f / WorkA5u14Jrt! 1 V0 1b Go j3 enl f ar*i _ h,-OQm C 10bV5, Alteration of existing bedroom Yes No Adding new bedroom Yes _1 No Attached Narrative Renovating unfinished basement Yes _ r No Plans Attached Roil -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? ,v— d. Proposed Square footage of new construction. Dimensions e. Number of stories? - // f. Method of heating? (3-c%`� Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? Q r In Type of construction_ R',19 V yf 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_ T`- / k. Will building conform to the Building and Zoning regulations? V 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 I. as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, I � J 0 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 ''unndder the pains and penalties of perjury. Print Name //' L" 11 `G Signature of Owner/Agent Date r 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 narking) #of Parking Spaces Fill: (volume&Location) _ ... . . ... .. ..... ....._ A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW 0 YES 0 IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 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 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 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 di-YES'turh r-..tearing, gradingnvation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? O NO IF YES,then a Northampton Storm Water Management Perm it from the DPW is required. • Department use only City of Northampton Status of Permit: Building Department Curb Cut(Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of'Structural'Plans Rune 413'587-1240 Fax 413-587-1272 Plot/Si te Plans Other Specify _ APPLICATION TQ`CQNSTRU T,ALTER,,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTIi:SN 1 -SITE INFORMATION 1.1 Prope Address: This section to be completed by office �, IJ 0 t-VN �A tit f'?itr �)_i Map Lot Unit Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: N r.3-'43--YG 5" yL `, Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item imated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building ' LU ®� ,{ (a)Building Permit Fee 2. Electrical -."w (b) Estimated Total Cost of Fzj) 0 J 0 Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) p to'o't 5. Fire Protection t _. 6,_Total=_t1_+2+3_+4±5) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building-Commis sioner/Inspector ofBui mgs Date File#BP-2008-0513 APPLICANT/CONTACT PER' ROCKETT TIMOTHY J ADDRESS/PHONE 7 UPLAND LEED (413)563-4659 Q PROPERTY LOCATION 160 NOR1 M LE ST MAP 17A PARCEL 218 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Af Typeof Construction: REPLACE DRYWALL ENLARGE BEDRM CLOSET&INSULATE&UPGRADE ELEC&PLBG New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets X Plans/Plot Plan THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 olition 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-2008-0513 GIs#: COMMONWEALTH OF MASSACHUSETTS { CITY OF NORTHAMPTON Mot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2008-0513 Project# JS-2008-000771 Est. Cost: $20000.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 11369.16 Owner: ROCKETT TIMOTHY J Zoning: URB Applicant: ROCKETT TIMOTHY J AT. 160 NORTH MAPLE ST Applicant Address: Phone: Insurance: 7 UPLAND RD (413) 563-4659 LEEDSMA01053 ISSUED ON:1113012007 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE DRYWALL ENLARGE BEDRM CLOSET & INSULATE & UPGRADE ELEC&PLBG 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 11/30/2007 0:00:00 $100.001017 212 Main Street, Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo