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42-091
City of Northampton Massachusetts c DEPARTMENT OF BUILDING INSPECTIONS 212 Main Street • Municipal Building ZJd cs� Northampton, MA 01060 INSPECTOR Louis Hasbrouck Chuck Miller Building Commissioner Assistant Commissioner HOME OWNER EXEMPTION ACKNOWLEDGEMENT The S e of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to ac s his/her construc i supervisor. The state defines"Homeowner" as, " Person(s) who owns a p cel on which he/she resid or intends to be, a one or two family dwelling, attached or detache structures accessory to su use and/or farm structures. A person who constructs more th one home in a two- year period shall n be considered a home owner." The building department the City of Northampton wants any pe soo )who seek to use the home owner exemption, to act as t 'r own construction supervisor, to be ware that by doing so you become responsible for comp ' nce with state building code and regulations. The inspection process requires that the building d rtment be called to insp ct work at various stages, which include (before work is concealed), Insulation fhape * uIred) and a final.building Inspection, The building department requires these inspe 'ons bef a the work is concealed, failure to secure these inspections can result In fallur obtai rtificate of.occupancy until the work can be e ins p cted• If the homeowner hires other trades to perform ork(el rical, plumbing &gas)the homeowner will be responsible to make sure that the trades hire secure their oper permits in conjunction to the building permit issued, and that they get their re fired inspections. ailure of the individual trades to secure the permits and inspections as required n DELAY the project til such time as the proper permits and inspections are made I, unders nd the above. (Home owner/resident's si ature requesting exemption) I will call to schedule all require building inspections necessary for the buildin ermit issued to me. Date Address of work location City of Northampton 212 Main Street, Northampton, MA 01060 Solid Waste Disposal Affidavit In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building permit all debris resulting from the construction activity governed by this Building Permit shall be disposed of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A. Address of the work: 2oG -& &L�— The debris will be transported by: The debris will be received by: Building permit number: Name of Permit Applicant '9/z. Date 4ignatu:reje Permit Applicant The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations p 1 Congress Street, Suite 100 Boston,MA 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual)' , Address: /oo Bax d 2 City/State/Zip: a/o 9,6 Phone #: 31'13-6X-5 -7a" Are you an employer? Check the propriiate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.� I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, E] Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their i l.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.[ oof repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13.[:] Other comp. insurance required.] *Any applicant that checks box#1 must also fill 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. tContractors 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 employees. 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 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 Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct Si afar Date: Lip Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number GZ 7hj�1G Address Expi tion ate %/3 Signatur Telephone ; 9 Reuistered Home Improvement Contractor: Not Applicable ❑ ,4 -- 156114/6 Company Na Registration Number o. S 2 a/o9c 5�3�ib Address Expirdtiob Date Telephone 4//3 -69S-70 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....... i�r' No...... ❑ 1. - Home Owner Exem tion The current ption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) o(2)families and to allow such eowner to engage an individual for hire who does not possess a license, rovi that the owner acts as su ervisor.CMR Sixth Edition Section 108.3.5.1. Definition of Homeowner: on(s)who own a parcel of land on which Eod ashafl ntends to reside,on which there is,or is intended to be,a one or tw ily dwelling,attached or detached ssory to such use and/or farm structures.A person who constructs mo an one home in a two- ear t be considered a homeowner. Such"homeowner"shall submit to the Building icial,on a form ptable to the Building Official,that he/she shall be responsible for all such work performed under th ildin ermit. As acting Construction Supervisor your presence on t to will be required from time to time,during and upon completion of the work for which this permit is iss Also be advised that with reference to Chapter 2(Workers'Compensati and Chapter 153(Liability of Employers to Employees for injuries not resulting in De of the Massachusetts General Law otated,you may be liable for person(s) you hire to perform work for you unde is permit. The undersigned"homeowner"ce ' es and assumes responsibility for compliance with the Building Code,City of Northampton Ordinances,State d Local Zoning Laws and State of Massachusetts General Laws ted. Homeowner Signature SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ff Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[O] Other[a Brief Description of Proposed Work: Alteration of existing bedroom Yes ✓ No Adding ne bedroom ✓ No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.If New house and or addition to existing housing, complete the following: a. Use of building:One Family V 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 y1*1 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 as Owner of the subject property hereby authorize , + � to act on my behalf,in all matt elative to rk authorized by this building permit application. >( A'-�"a q za;�.!r '\ Signature of Owner Date l as Owner/Authorized Agent hereby are that 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 cage 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 parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO t DONT KNOW © YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO ® DONT KNOW 0 YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO t DONT KNOW ® YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES ® 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 disturb(clearing,grading,excav tion,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ® NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ( Department use only �- city O , hampton Status of Permit: 2 9 2 Idi ' partment Curb CulfDriveway Permit SE 212 al Street Sewer/Septic Availability 00 Water/Well Availability piurrl�i^gl o A 01060 Two Sets of Structural Plans Oec�ric, o , -587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 2G6 Map Lot Unit Zone Overlay District Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ¢e4C -'tlami-e(Print) Current Mailing Address: „ / /�A �(_�i Telephone Signature 2.2 Authorized Agent: a. Bcrx G 2- O/0 Name(Print) Current Mailing Address: yr3 -6�s-7as� Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 2 Yoo " (a)Building Permit Fee i 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) 2 Yo<7°O Check Number This Section For Official Use Only Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date 206 GLENDALE RD BP-2016-0428 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:42-091 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ROOF BUILDING PERMIT Permit# BP-2016-0428 Project# JS-2016-000698 Est. Cost: $2400.00 Fee: $40.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: EDWARD RICKEY 96159 Lot Size(sq. ft.): 33018.48 Owner: MESSIER RAYMOND R&GERALD R&PATRICIA&R DAMON&D WRIGHT Zonine: Applicant. EDWARD RICKEY AT. 206 GLENDALE RD Applicant Address: Phone: Insurance: P O BOX 62 (413) 695-7059 WILLIAMSBURGMA01096 ISSUED ON.912912015 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE 4 SQ OF ROOFING & SHEATHING 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 Deaartment 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 9/29/2015 0:00:00 $40.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner