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06-003 (8) it af �.♦ a �It833a7C�3I5 G:i9 —_ DEPf'_;tTMENT OF EUILDr.,7G INSPECTIONS h+ iNSPECTOP 212 Main Street • Municipal Buikiin '��� Northampton, MA 01060 r HOME OWNER EAEMPTIQN ACICNGWEEDGENMENT SW The State of Massachusetts allows the homeowner the riaht under 780CMR 108.3.4 I act as his/l,.er construction sups._ .-::;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 structure person who constructs more than one home in a two-year period shall not be conside 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 superz Aso, 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 backfIl). sonotube holes (before pour). a roueh building insaection(before work is concealed). insulation inspection (if required) and.afnaLbuildine 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 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 L understand the above. (Home owner/resident's signature requesting exemption) I will call to schedule all required buiIdin4 inspections necessary for the building permit issued to me. y Date Address of work location The Commonwealth oflVassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeaibIv Name (Business/Organizatio diet ): O y P Liz Ko ih, Address: City/State/Zip: 1,)4p" 00,�1� Phone.1: Are you an employer' Check the appropriate box: Type of project(required): 1.-E I am a employer with U 4. ❑ I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 12- I a a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition I employees and have workers' wanking for me in any capacity. 9. ❑Building addition ��To workers'comp.ins�,u--ance comp.insurance.: required_] 5. 7 We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbmg repairs or additions myself o workers'co right of exemption per MGL o Y � work. - 1� ❑Roof repairs insurance requited.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp.insurance required-] ican caer oox' must ago n out a secaon beiowshowmg their workers'compensation policy information. Homeowners who submit this affidavit indicanniz the.+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-contcactors 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 employees. Below is the policy and job site information.. Insurance Company Name. Policy m or Self-ins. Lic. r: 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;�00.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fne of up to 3250.00 a day against tiie violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DLL for insurance coverage verification- I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. --�lgnafure: Date: Phone#- lJJ` LOther e only. 1�o not wrrle rrt thts area,.to be completed by city or town official wn: Permit/License thority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector Plumbing Inspector _ son: Phone T: SECTION 8-CONSTRUCTION,SERVICES 8.1 Licensed Construction Supervisor: 11 Not Applicable ❑ Name of License Holder: C5 06-57-zoy License Number mf ()10�)� 2- 1 -01 Address Expiration Date nature Telephone g Regisfered`FCorte lriipro�reiiient Contractor �„ r' _ _ m-` 4 Not Applicable ❑ �0���7 ,� Cola�r• i y 6 3W-2 Company Name Registration Number S 6ka--Cl, h3e10>zA, i QQK- - y- 11-(39 Address Expiration Date �51s� M/Q ; Telephone SECTION 10 WORKERS'COMPENSATION INSIIRANCE:AFFIDAVlT(M:G.L,c-1521§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...... ❑ 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 1083.5.1. 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 ayolicable) New House Addition ❑ Replacemedt,Windows Alteration(s) ❑ Roofing rxi Or Doors "4677 Accessory Bldg. ❑ Demolition ❑ New Signs [Qj Decks [M Siding[O] Other[O] Brief Description Qf Propos d x' / Work: i e�l/1 u2 otc-i e CJi'`,)90=11 v rUterat'ton of existing bedroom Yes No Adding newtedroom Yes o Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa Lf=`N`ev��orr<sa�at�d o�ac�dltio��-fi�:exlc�>Enc�:�o���tcr�-Eantolete_t�r��f��fov�ig: 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 o. is cons rue on ithin-100 yr. floodpliaii i 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-OWNERAUTHORIZATION-T-QBE COMPLETED WHEN OWNERS AGENT- APPLIES-FOFR BfIILDINC.PERMIT^ as Owner of the subject property hereby authorize to act on my behalf, in all matters i-fttivdi to work authorized by this building permit application. Signature of Owner V Date 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. ;�_ —: - a—'L JpL Q Print frame Signature of Owner/Agent Date J , 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 V Bldg.Square Footage Open Space Footage (Lot area minus bldg&paved parkin) #of Parking Spaces Fill: (volume&Location) a A. Has a Special Permit/Variance/Finding ever been issued for/on the site? ouv , IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW O YES 0 IF YES: enter Book Page: and/or Document#`. B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained Date Issued: C. Do any signs exist on the property? YES 0 NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES © NO 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. _ tleparfn7er�crse vt�- -��.�- City of Northampton Staffs omu y 3 _�—------ +id]ng Department CurCt(E] �ewe -r C �12 Main Street SewerFSept� Auaifabrlrt .Room 100 Mfer/W-etL�vaEtahii�e `^ Nortlp,,-mpton, MA 01060 pro Sets of ttactural PFans i SEP �hclW7413- -1240 Fax 413-587-1272 Plo] SffePlar} - A ?t ATIbN,>i(ti RUCT, LTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING nm k SEGO fQN =:SITE INFORMAIiOiY 1.1 Property Address: This sectfarr t lye,;:Pkopl'ete Ja offrc2 e ANfa €ot Ucrrl Li;II�'u �)��nc, ���. 2"a Srse oaesraartxrct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED.AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: O",4 Name(Print) Current Mailing Address: -ice-3 Signature Telephone SECTION 3-ESTIMATEU CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (aj-SuildingaPermit Fee 2. Electrical (b)iEstimated Total Cost of Construction..frcm 6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total =(1 +2+3+4+5) j Check Number 77 — This Section For OffieMUUse Only Building Permit Number: issued: Signature: Building Commissicnerilnspector of Buildings Date BP-2008-0347 QlS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2008-0347 Project# JS-2008-000497 Est.Cost: $3000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: RONALD KEITH 146380 Lot Size(sq.ft.): 28357.56 Owner: COGGSWELL RUSSELL&PATRICIA Zoning: SR Applicant: RONALD KEITH AT. 600 HAYDENVILLE RD Applicant Address: Phone: Insurance: 5 BIRCH MEADOW DR (413) 584-5589 HADLEYMA01035 ISSUED ON.101112007 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE WINDOWS/SILLS & ROLLED ROOFING 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 10/1/2007 0:00:00 $25.003572 212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo