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31B-162 (8) r21 y 7"ne tat?Of-MassacL=set-is allows the hGn'.eGw r the r:Cr I:Ilder%$JC. i`Z I08.3.-^ t act a` L: i;e. CGI1StZLCt?Gn Sup 'SCF. ie State '° IIeS `tiomeGtiYer dS <: erSGn(S) who o-"MS a parcel on wrlich he/she resides or intfends to be, a one or two fa3nily attached or.detached strict:res accessor✓�tc Such use and/or fa, st:uct�es. A person—ho cons`L.--dcts more than one Some in, a tpic-year period shall not be considered a home ovaner." Tne bold as=dep ent for the City of Nor` --:d ton wants any person(s)woe sees to use the hotne C Vvmer exerptloL, tG act as their owt. co t u on per:'.s:', that by doing so you become responsible for comjpliance with state building codes and regulations_ The insae ion. process req T7Fes that the building depar ent be called to i=per work at vinous states, which include fogndnt on/footings (before back-511). sonotube holes ('before oour). a rough buRdina*saection (before work-is carscg.-ged). ijis`lation inszectian (if recuire3) a4d-a f-Inn? b-uildina.insnecti.en. The b ,; ding deponent requires these inspections before the work is concealed, failure to secure the inspe--tions can result in failure to obtain a certificate of occuDancv untU- -n�-be-insnected.- . U-the homeo--ner hires other trades to per form W04(electrical, pl=bing&has) the homeovner rill be responsible to mak-e su_Te*h at L, traces hired sure their proper permits In Conj=-Ctlon to the building pe=..it isS,�ed,',an-d that they get their required inspections.Failure of the indi✓ideal trades to sec-ark the permits and inspections as required can DiJLA Y the protect u_:til such*tee as te proper pe=its and inspections are made v �-y im-der.stand the above_ (Homy_owner/resident's signature requesting ellemption) I will call to schedule all required building inspection$necessary for the building per=t issued to me- t7ate 2 Zd I©6 A o woric _ location � `J ' n.� �``e. Avlor d/0/,-o i _.� Depart/IzL lit Of,' �ii �_A &ents Of of'Int,esti,atiotrs 600 J ashin-ton S=reet _ - Boston, !L14 02; t t www.mass.aoldia NVorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A prpdic.lnt Information Please Print LeaivlY Name (Business%Organization/Individual): _ A aa_ c�uui eJJ. Ciro/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1.❑ I am a employer-with �. ❑ 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. ❑ Demolition working for me in any acity.ca p employees and have workers' 9_7 Building addition [No workers' comp. insurance camp. insurance. req�_tired.] 5. f7 We are a corporation and its 10.F71 Electrical repairs or additions X F am a homeowner doinc all work officers have exercised their 11.7 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12 ❑ Roof repairs insurance required.] c. 1�?; §1(4), and we have no q 13.❑ Other employees. [No workers comp. insurance required.] *:Any applicant that checks box rl must also fill out the section below showing their workers'compensation policy information. Ho meowners who submit this affidavit indicatin.-they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that checl<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: Poiicv#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 tine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of InvestiLmtions of the DIA for insurance coverage verification. I do hereby certify tcrrder t/ze rrtfpeirahies-o perjury-that the information provided above is trace and correct. Signature: f v 2 Date-- Phone __QcittLarse_r�rzl�, DU1z.oLrvrite iztlla'is_ttrea to be completed�._city or town_off_zcrz� — – -- - City or Town: Permit License# - - Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Clty;Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other �� Contact Per son: Phone: i 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. "f Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT gM.G.L.c. 452,§25C(6)) Workers Compensation Insurance affidavit must be completed and subm�tted 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...... ❑ r 11. - 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 W°ho 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 two-year 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 slite 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' gompensation) 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 Zom La sand State of Massachusetts General Laws Annotated. Homeowner Signature Lla I SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding [0] Other Brief Description of Propos d t ; Work: f A T-i,ci(Ct.�i C2 o' of �(/ood 6�jLiLr, yye Alteration of existing bedroom Yes No Adding new bedroom Yes 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 Two Family Other b. Number of rooms in each family unit: _ Number of Bathrooms c. Is there a garage attached? fV✓ d. Proposed Square footage of new construction. Dimensions e. Number of stories? �.. p� � / j p � sFUb'e f. Method of heating? f� is t,'r ` �,�i rq h(f Fireplaces or Woodstoves ' �1r '1. 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 as Owner of the subject property hereby authorize to act on my behalf, in all rlafters relative to'l,,Qauthorized by this building permit application. Signature of Owner Date Ct✓Ir as Owner/Authorized Agent hereb decl re that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under a pains and penalties of pe,r ry. Print Name Signature of Owner/Aifent Date e 4 Section 4. ZONING All Information Must Be Completed. Piormit 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) _........... ,...._.,_v. ._,_ _. __,......._. A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES Q 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'Ifrom the Conservation Commission? Needs to be obtained Obtained Q , 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 disturb(clearing,grading,a cav 'tion, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES O NO IF YES,then a Northampton Storm Water Management Pgrmitfrom the DPW is required. Department use only ,of Northampton Status of Permit: ( 1 n V Buildjng Department Curb Cut/Driveway Permit 212.Main Street Sewer/Septic Availability 2QQ� Room 100 Water/Well Availability �pR Northpmpt, n, MA, 01060 Two Sets of Structural Plans phone 413,587-124Q Fax 413-587-1272 Plot(Site Plans --''� Other Specify \APPLIckrm TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be completed by office 1.1 Property Address: c� Map Lot Unit Zone Overlay District �®!j d 0 Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: (' ' 1— Name(Pn Current Mailing Address: S f ,p ol, c Telephone 2 (" p Signature ✓ J 0 6 2.2 Authorized Agent: Name(Print) Current Mailing Address: 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) Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: f Building Commissioner/Inspector oBuirdings' Date I BP-2008-0759 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: woodstove BUILDING PERMIT Permit# BP-2008-0759 Project# JS-2008-000074 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 44431.20 Owner: ROTHER BRYANT P Zoning: URB HD Applicant: ROTHER BRYANT P AT. 159 ELM ST Applicant Address: Phone: Insurance: 159 ELM ST _(413) 586-1424 0 NORTHAMPTONMA01060 ISSUED ON:311012008 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector t'nderground: 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 3/10/2008 0:00:00 $25.003979 212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo 159 ELM ST BP-2008-0759 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 31B- 162 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: woodstove BUILDING PERMIT Permit# BP-2008-0759 Project# JS-2008-000074 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 44431.20 Owner: ROTHER BRYANT P Zoning: URB HD Applicant: ROTHER BRYANT P AT: 159 ELM ST Applicant Address: Phone: Insurance: 159 ELM ST (413) 586-1424 O NORTHAMPTONMA01060 ISSUED ON:311012008 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE 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: C S7`ovf Final: Smoke: Final: a l< pa' G,outs l y THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancv si nature: FeeType• Date Paid: Amount: Building 3/10/2008 0:00:00 $25.003979 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Conunissioner-Anthony Patillo