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17C-284 (4) ¢ZttAt-f P�. I- a E (ref of �1Zr#Ij�)lt}�tDl1 - — asisAchn,:ctIa' w DEPARTMENT OP BUILD010 INSPECT10t,,s 212 Alain Strcct Municipal Building Northampton, Mass. 01060 WOrUCER'S CONI[PENSA'nO.N UNSURACE AFT'DDAVI I, (li�tsxJps�-rmI ttcc) %vilh a principal place of businessfresidenee at: - - - (phone') t-Y llnalcla P) do hereby certify, under the pains and penalties of pc,3wy, hzi i ( ) I am an employer providing the following!workci✓s comocnsanop. cove Sc for Intl Cluployces wol-Lang on Lilts job: i (Irsw--n=Coax ) (PP.Lic:Numhcr) (T_:'pi>vt!on Day.) O I am a sole proprietor, general coom-actorror homeowner (c cie one) and Dave hired the coasactgrs listed below wbo hive the foilgtvin9- workees camoensation pokiest (1tHM Oi CO„^ci0r) (Inst!ranc:. Colnoan}'/Pout; NwMh-CI) (X7)Inl3on Datc) j -- (Namc of Coamczor) (lrls-w7a2.:. Como_'axvi?oum, Ntac^r) (t.%Dirz6on Dale) i (Name of Conuaao:) (insurance Com-pan y/Pouch' Nambu) (Eapirsdon Da1c) (NaMc of Councior (LruZlrancc Compan-ylPoucy Ntlmbcr) (E.%Pirtion Datr). (atxaG�l itioc�l cbcc,if acc�a�•to a,cu6c•iarocmAzion pctaiaiag 0.o 41 { ) I am a sore proprietor and bave no one work.ng for me. I am..a home owner performing all the work myself. NOTE:plcu be cw-uc tom:.j ]a 6cmco.m,=-bo c=plo),ix-u;rw w do n= c=--zajoo c rcp2a..-orz ca c d%%xll_F,of ace mete tbca b w•marj is winch ttx bom000vcr rcaed�oc oa the pm z4;,a7purtcrarl tbeco c.-c oa C-, cmuy cc^-:dzni to be caVloycs unGr the-vz; -c=mp -.,:ca Act(GL152..n 1(5)).:Wucaboo by a bommavc fm a licz.-cc pcmit rzy--id—tl:c Icg-.i n..,,.or en ernioyar under d,o WockzeL Cooapoosation AeL 1 uadca.aad dla a copy of tbic mtcm1 m,.y ba fo—.nrdnd to tbu poparrmma of Inda,.sricl Accdoata'Ofsoe or 4rra.00e for tE- oovczsc vcif atioa and U%-A •iltzc to,.==`covcrngc bade sccaiop 23A ar l.(oL 152 c=c ltd to tba im C oa of cimia,l pca,ltia ooaiiz tag of a tint orup to s 1_5oo.00 andfoc o(up Lo pot ycr c od c»1 pmahia io 6c room of a Stop Wori Ord and a fin=o(:s 100.00 a d_y tpimd me For deq.rta,,�al uie only '--•--' per- lit NUMLcr ra / 1 e !7 hen.__ Lo( Siena of Lic�tscclPcrmittcc � -- -� �- O���MpTO Crzty of Xarf4a ptan z � � j�iiassxc3tusetfs - g DEPARTMENT OF BUILDD,,TG INSPECTIONS /= INSPECTOR '212 Main.Street • Municipal Building Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as has/her construction sup,.: sor. T he 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, 1 r � understand the above. (Home owner/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 location Z9 L lL L , Sr Fze;e6u,--c 141q a 1 v l SECTION 8-CONSTRUCTION`SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Not Applicable ❑ 9wRe stere"�Hofne" ia"�crverrrr>en�<Cai�ractoE . '�', Company Name Registration A—um � ee _ Address Expiration Date Telephone SECTION 10 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(RA.L.c.1-52,1,25C(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 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 y1rmit. 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. 11 Zo Homeowner Signature ? 1Jr �Cr r 'i SECTION 5-DESCRIPTION OF PROPOSED WORK(check'aihayolicable) New House [-� Addition [_]:: Replacement Wirylows Alterations) Roofing 0 Or Doors 0 Accessory Bldg. Demolition ❑ New Signs [0] Dgcks Siding[p] Other[01 tivL Brief Description of Proposed Work: .�Q�t -a Alteration of e)asting bedroom Yes No Adding new bedroom Yes No . Attached Narrative Renovating unfinished basement Yes No Plans Attached Roil -Sheet sa=E Nev ias� i d d i c e eici�t a s i o n e��P lice a f v nd: t/ a. Use of building:One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms 2 C. Is there a garage attached? NL� d. Proposed Square footage of new construction. /ZIIK� 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 No. Is construction within 100 yr. floodpiain 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 l �,, hereby authorize NU ffAeL la)U4 y 11— to act on my behalf,in all matters relative to work authorized by this building permit application. m 1-42,5 Signature Owner Date i, 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. Print Name Signature of Owner/Agent Date Section 4. ZONING All Informatioh 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 I Setbacks Front Side L R:' L R:! Rear Building Height Bldg.Square Footage % --r l 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? N0 0 DONT KNOW 0 YES 0 IF YES, date issued:: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES Q IF YES: enter Book I Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO f�— DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: j D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q 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 i IF YES,then a Northampton Storm Water Management Permit from the DPW is required. a "- it, of Nort am ton P `° Y � p if�ding Department J, P Main Street 2CU5 Room 100 var�a � orth mpton; MA 01060 s��ti �ra� r�s MOM �St _phone,; -58 -1240 Fax 413-587-1272 r"tatkS�d ata ' st"35, .0 ___-APPLICATION TlO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1--SITE INFORMATION 1.1 Property Address: This section to beAcomplefedblrofflce Lot UrF t AA 2— Zone OVerla District �IC7lo _ � F � ECrttSf Distrrct CB Disfnct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: lkMY A BAS 2.9 LILLY SE &1J& YA 0100 Name(Print) Current Mailing Address: Telephone Signature 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 ' G (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 Kv This Section For Official`Use Onl Date . Building Permit Number. Issued: Signature: !' Building Commissioner/Inspector of Buildings Date J File#BP-2006-0072 APPLICANT/CONTACT PERSON BAIRD BETSY A ADDRESS/PHONE 28 LILLY ST FLORENCE (413)586-4430 Q PROPERTY LOCATION 28 LILLY ST MAP 17C PARCEL 284 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid R Typeof Construction: REPAIR GARAGE FOUNDATION&CREATE SMALL STORAGE ROOM 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 INF9KNIATION 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 ommission L 1200 S 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. N 28 LILLY ST BP-2006-0072 GIs#: COMMONWEALTH OF MASSACHUSETTS MU-Block: 17C-284 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2006-0072 Project# IS-2006-0097 Est. Cost: $3500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Groin Homeowner as Contractor Lot Size(sg.ft.): 10890.00 Owner: BAIRD BETSY A Zoning:URB Applicant. BAIRD BETSY A AT. 28 LILLY ST Applicant Address: Phone: Insurance: 28 LILLY ST (413) 586-4430 () FLORENCEMA01062 ISSUED ON.7122105 0.00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR GARAGE FOUNDATION & CREATE SMALL STORAGE ROOM 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 SiEnature: FeeType: Date Paid: Amount: Building 7/22/05 0:00:00 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo /�4oh'-- G11ti7" 4_A- ���� BP-2006-007 . 28 LILLY ST COMMONWEALTH OF MASSACHUSETTS GIs#: CITY OF NORTHAMPTON Map:Block: 17C-284 Lot: -001 Permit Building BU ILDING PERMIT Category_ Permit# BP-2006-0072 Project# JS-2006-0097 Est.Cost: 35� 00.00 PERMISSION IS HEREBY GRANTED TO: Fee: 50.00 Contractor: License: Cons_ t•Cs:lass: e_-Group: Homeowner as Contractor Us Lot Size(sQ ft)• 10890.00 Owner': BAIRD BETSY A Zoning:URB A Iic BAIRD B�A AT: 28 LILLY ST Insurance: Phone: Applicant Address: (413) 586-4430 28 LILLY ST FLORENCEMA01062 ISSUED ON.7122105 0.00.00 O PERFORM THE FOLLOWING WORK.-REPAIR GARAGE FOUNDATION & CREATE SMALL T STORAGE ROOM POST THIS CARD SO IT IS VISIBLE FROM llT H E STREET Building Inspector Inspector of Plumbing Inspector of Wiring Service: Meter: Underground: Footings: Foundation: 1)�� House# Rough: Rough/�/ y A/� llriveway Final: Final: Final: �A2P4 Rough Frame: 240/0 RAf Q✓�q�r L P Fireplace/Chimney: Gas: ire Department (-� ©� �t M Insulation: Rough: Oil: Final: OK 1��2�f aS L��nls Final: Smoke: THIS PERMIT MAY BE 12EVOhXD BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES ANI) REGULATIONS. Si nature: Certif cat_cu anc Date Paid: Amount_ Feel e: Building 7/22/05 0:00:00 $50.00 212 Main Street,Phone;(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo