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17D-046 (2)
7 C) 2 N 1 S A C,106 "tar rVNTnWLEDC-E--,V-rENT A A I ACJ-, AA, I ER Ar A 111 The Stave o1rMassach-use-,s, allows ti'I-- home-Owner the 1-Ight under 780c--,\,a 108.3.4 to sV I - -�r , -ne,-7, a�s, erson(s) I who 'Or o-,,-r-, a parcel on wliich he/sae resides or intends to be, a ore or twofanziyy es accessory to such use and/or fa:=- structi-,-.es. A- Led attacl- or detached- nvc-year Period Shall not be 'd person_Who Cons-Lructs more than one home in a considered a home owner." T'he build-in 7=departmeat for the CI-,; Of North'a-a2pton Wants any person(s)who, seek to use the home Ovvmer exemption, t c ac. ;m Cc==L:I--"On to codes that by doLT,2 so v©u become responsible for compliance with state buildin= and re-,-2a&ns'.T-Te ir-s-,e-.tion process requires that the building department be called (before backTUD. to i:lspecct wore a various stages, -which include foynd2tion/footinsls efOr sonotube holes (before ootir) a rough building ixispection(before work is co-rcetje&-. i s latiah ins ectiun (if required)aka TmaLT-hufl In i=e--tion. T-he I concealed, failure building depa=ent requLres these before the work is conc: ed, f - re to secure the,se inspections can result in failure to obtain a cc--tificate of occupanc-v until-the-wank- car-be-inspectzd- 11-7the hc=eowaer hires other'Lades to perform work (electrical, plumbing&gas) the trades hired secure their roper- homeown-e—r will be respor--ible to r:alke sure tllatt the proper permits in Conj=ction to the building Permit issued, and that they get their required inspections.Failure of the individual trades to se,--,Ye the permits and inspections as ions are rewired can, D-EHAY th e pr,-i-- unit"il such time as the proper permits and inspect' made ------ underrand the above. (Home owner/resident's signat-ure requesting exemption) 'ld,:Lz- pen I will to schedule building the b LZI 2 all r-cured bLT -mspec+,-ons necessary for e issued to me. Date location ( LeJJ ZZI t,-r urrfa LL .,Z LJ Of�jtce of Investigations 600 ff'ashinl;ton Street -.. i- Boston, —4 02111 - wivw.nzass.,ovIldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/,'Plumbers A oolicant Information Please Print Lezibl Name (Business!Oraanizationilndividual): City/State/Zip: Phone Are you an employer? Check the appropriate box: Type of project (required): 1.❑ I am a employer'with 4. ❑ I am a general contractor and I ertiployees (full andior part-time). have hired the sub-contractors 6. New construction -.P I am a sole proprietor or partner- listed on the attached sheet. i. ❑ Remodeling ship and have no employees These sub-contractors have g_ ❑ Demolition working for me in anv ca acity. employees and have workers' P 9. F7 Building addition [No workers' comp. insurance comp. insurance.+ t eq�_tired.] 5. ❑ We are a corporation and its .0.❑ Electrical repairs or additions ❑ I am a homeowner doing all work officers have exercised their 11.7 Plumbing repairs or additions myself. [,No workers' comp. right of exemption per MGL 12.7 Roof repairs insurance required.] c. 152 §1(4) and we have no employees. [No workers' 13.0 Other comp. insurance required.] 'Any applicant that checks box mi must also fill out the section below showing their workers'compensation policy information. Ho meowners who submit this affidavit indicating 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. lam an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: _ Policv,`,-or Self-ins. Lic. 7: 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 S 1,500.00 and/or one-yeas 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 Investigations of the DI.A for insurance coverage verification. I do hereby certify°-rctrdertlze-pains-=ttpen-alties-of-pexjmy-that the information provided above is true and correct. Signature: !°r' z z cr` Date: Phone j fcial-lase_orzli .�U�.otarzite�nlh s_aze_a�to b completed by city or towzz 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 I' b. Other iI Contact Person: Phone =: 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 Cont4acf6r: Not Applicable ❑ Com a r Registratidn Number ddre _ Expiration Date � Telephone_ SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.132,§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...... ❑ 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 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) r' New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding [O] Other[LI] Brief Description of Proposed Work: !/✓ 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? 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 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 f A as Owner of the subject property .r hereby authorize to act on m y,behalf, in all m rs el ive_to work a rith orized by this building permit application. Signature of Owner Date as Owner/Authorized Agent hereby'ded are that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. V Si g ned and r t e pains and penalties ofpAvyy. !— °-- Print Na _ Signatur of Owner/Agent L Date �,f 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: 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 0 DONT KNOW Q 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 Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 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 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 0 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 O NO O IF YES,then a Northampton Storm Water NlanagementPermit from the DPW is required. r Department use only pity:of Northampton Status of Permit: l ' Building Department Curb Cut/Driveway Permit _ 212 Main Street Sewer/SepticAvailability --'doom 100 Water/Well Availability Nortoamp�on, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other<Specify _A -PtiCATION 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: -r—. rG.�.'Cl- Map Lot Unit -7u '" Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ` Name(Print)) r -- Current Mailing Address: � Telephone Signature 2.2 Authorized Agent: 7 Name(Print) ✓ Current Mailing Address: Signature:' Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only co eted by ermit applicant 1. Building d (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 67 AM This Section For Official Use Only Date Building Permit Number: Issued: Signature: Budding Commissionedlnspectof uirdings Date I ' BP-2008-0756 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: roofing BUILDING PERMIT Permit# BP-2008-0756 Project# JS-2008-001172 Est. Cost: $5000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: James Roberts 117154 Lot Size(sq. ft.): 5183.64 Owner: KRISTEK BEVERLY&DEBORAH FULLER Zoning: URB Applicant: James Roberts AT: 70 STRAW AVE Applicant Address: Phone: Insurance: 30 Edwards Rd (413) 527-6078 WESTHAMPTONMA01027 ISSUED ON:31612008 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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: heeType• Date Paid: Amount: Building 3/6/2008 0:00:00 $25.00579705 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo