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31A-101 (2) ..- _. . ... BP-2007-0722 GIs a. COMMONWEALTH OF MASSACHUSETTS �`s t<" CITY OF NORTHAMPTON Loc -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Caterer, BUILDING PERMIT Permit# BP-2007-0722 Protect# JS-2007-001100 Est. Cost: $450.00 Fee_s25 00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Us Croat,: Homeowner as Contractor_ Lot Size(su.h.). 12763.08 Owner: WALDMANAMYI&AMYMAR'IYN Zonine-URB Applicant.- WALDMAN AMY I & AMY MARTYN AT. 17 FEDERAL ST Applicant Address: Phone: Insurance: FLORENCEMA01062 ISSUED ON.-111812007 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL PELLET STOVE POST THIS CARD SO IT IS VISIBLE FROM THE STREET I nspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House!# Foundation: Drive,'.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: FeeTvpe: Date Paid: Amount: Binding 1/18/20070:00:00 $25.001749 212 Main Street.Phone(413)587-1240, Fax: (413)587-1272 Building Commissioner-Anthony Pat1110 Dom'- bprierMvseor City of Northampton StaWsyA`p L" a.. a Building Department niuC' 212 Main StreetTARp - ut Room 100 .q .�a#dar ssx 4x, e asr � Northampton, MA 01060 wg- S�rchirafElans 'Y" T "` vT: phone 413-587=1240 Faz 413-587-1272E1oPlans`"- OttlerSveaN s _ APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION - 1.1 Property Address' This sechonto 6e completed by office ,Map - Lot Unit Zone Overlay District C 1 C6Z - - EMSL_Distribh " - - CBDistnct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: t U AA —I t Name(k) Current Mailing Address: d 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 permit as licant 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: Building Commissioner/inspector of Buildings Date Section 4. ZONING All Information Murt Be completed.Permit can Be Denied Duarte Incomplete Information Existing Proposed Required by Zoning This cdlnnm to be filled in by Building Do ours nt Lot Sue Frontage Setbacks Front — Side L:— R:— L:-- R_ _ Rear Building Height Bldg.Square Footage 51. Open Space Footage _. % — (totads&faced — arL kofparking Spaces Fill: —-- (volume&Lacenan A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O DONT KNOW © YES O IF YES, date issued:'. IF YES: Was the permit recorded at the Registry of E eeds? NO © DONT KNOW © YES O IF YES: enter Book Page, and/or Document#' B. Does the site contain a brook, body of water or wetlands"' NO © DON7 KNOW O YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained © Obtained V, 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 sicns intended for the property? YES © NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excs+afion,or filling)over 7 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 Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK ficheck aftapplicable) New House Addition ID Replacement Windows Alteration(s) Roofing Q Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs (M) Decks I❑ Siding [D] Othor[EE] rof Description of PJgposetl Work: Alteration of existing bedroom_Yes ✓No Adding new bedroom Yes ✓No Attached Narative Renovating unfinished basement Yes ✓No Pt ..Attached Roli -Sheet —'— Sa-If New hotlse r#ndora7AiYIon Yo exia,,fmatou`sino co'i`nu)efafiet'ol[o'vfna a. Use of building: One Family Two Family_—Other S Number of roams in each family unit Number of Bathrooms C. Is there a garage attached? d. Proposed Square footage of new construction._-Dimensions _ o. Number of stones? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction _ 1. Is construction within 100 ft.of wetlands?_Yes _No. Is construction within 100 yr. floodplain_ _Yes_No I. Depth of basement or cellar floor below finished grade, k. Will building conform to the Building and Zoning regulations? __Yes No. 1. Septic Tank_ City Sewer_ Private,"ll­ City water Suppty__ SECTION 73-OWNER AUTHORIZATION-ATO BE COMPLETED WHEN OWNERS AGENT OR:CONTRACTOR APPLIES FOR BUILDING PERMIT I, —_. as Owner of the subject property ""— hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. SignaWre of Ownernn Date JAgenthereby Fl M y1/t cs' {—�.-� ,as OwneriAuthorized tleda2 that a statements'antl mforrnatign on the foregoing application are trueend accurate,tothe Gest of my knowledge beliefed under t(he pains and penalties of perjury. Is f �Owner gem p to SECTION 9-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder:_ _ License Number Address i Expiration pale Signature Telephone 9v:Re'pistdred-H'odiefenorovainelttCOMzacfot' y:yu„� `-.y% ; Not Applicable ❑ Gompam.Name Registration Number Address Expiration Data Telephone_. SECTION 10-WORKERS'COMPENSAT70N INSURANCE AFHDAVIT(MIO.t..c.152,§25C(5)) Workers Compensation Insurance affidavit must be completed and submit ad with this application.Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes....... 0 No...... ❑ ',E Wit$ a" �x`t-_'-fi'r: "�O1llCe HcD'$ BCIIIAOI1 The current exemption for"homeowners"was extended to incl ide Owuer-occupied Dwefiines of one(1) or Two(2)families and to allow such homeowner to engage an individual for hire,>ho does not possess a license,provided that the owner acts as supervisor.CMR 780. Sixth Edition Section 1083.5.1. Definition aEHorpeowner Person(s)who own a parcel of leaden which he/she resides or intends to reside,on which diene is,or Is intended to be,a one or two family dwelling,attached er detached structures accessory to such use and/or faint structures..A person who constructs more than one home in a two-year added shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official.that heishe shelf be responsible for all such work Performed under the buiidina permit As acting Cote tra etiois Supervisor your presence on the job z he will be required*am 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)ofthe Massachurens General Laws Annotated,von may be liable for persons) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes responsilility for compliance with the Send Building Code,City of Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated, Homeowner Signature � � The Commonwealth of Massachusetts Department oflndustrial Accidents ions OfficeWashington gtovestn Street 600 Washington Street Boston,MA 02111 www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibly Name(Business/Orgmization/Individual): Address: City/State/Zip: Phone.#: Fre n employer?Check the appropriate box: Type of project(required): a employer with 4. ❑ I am a general contractor and I oyees(fill]and/or part-time).' have hired the sub-contractors 6. ❑New construction a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling rad have no employees These sub-contractors have g_ ❑Demolition ing for me in any capacity, employees and have workers' co insurane,,1 9. ❑ Building addition orkers' comp.insurance »$ ed] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. rNo workers'camp, right of exemption per MGL insurance required.] t a 152, §1(4),and we have no 12.L]Roof repairs employees. [No workers' 13.0 Other corm. insurance required_] 'My applicant Nat the Lx box#1 mus[also fill ourthe s fivcbelowshowingtheirworkers'wnrymsation polityi�Sormatlon. t Hommwners who subrmt Nis affidavit indican,they are doing all work and Nm onase hire outside ctors.."Amt a new affide a mdimtln¢such. [Contractors Nab check Nis box rota[attached an additional sheet showing Ne name of the sub<y v acbrs and crate whether orno�those rntities have employees. If the subcontracmrs have employees,they mart prwid<Nnr workers'comp.policy nomber. I am an employer that is providing workers'compensation insurance for my employees. Below is the poh2y and job sfte information. Insurance Company Name: Policy H or Self-ins. Lit k: 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 e. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fie 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 insim ce coverage verifrcati I do hereby certify under the pains and penalties ofperjary that the information provided above is true and correct Signature qg ����..�� Date: Phone# C, 2 SZ Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License S Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Persom Phone b: Gr fp of Nart4ampton B' B yAnn«ohna..Hv B I^ I m DEP.4FTtdEU"r OF BUfIDt7�G INSPECYIONS ),,";y 212 Main Street • Mu aleiral Building INSPECTOR Norttrunpam, M4 0[W e HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowne-the right under 786CMR 108.3.4 to act as his/her construction sup.: .;sor. 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 divelling, 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 homeowner." The building department for the City of Northampton wants any person(s)who seek to use the home owner exemption, to act as their owl 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/footinzs(before backrill) sonotube holes(before pour). a rough buildim inspection (before work is concealed), insulation inspection (if required) and a final building inspection. The building department requires these inspections be-ore the work is concealed, failure to secure these inspections can result in failure to obtain a certificate of occumme 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 se+;ure the permits and inspections as required can DELAY the project until such time as the proper permits and inspections are made u( h _ understand the above. �/ (Home owner resident's signature requestiig exemption) \` I will call to schedule all recuired building inspections necessary for the building permit issued to Inc. Date_ 1 ' Address of work location