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23D-154 (6) f BP-2005-0209 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A) Category: BUILDING PERMIT Permit# BP-2005-0209 Project# JS-2005-0258 Est.Cost: $6000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: GEORGE KOEBER 063492 Lot Size(sq.ft.): 44431.20 Owner: SNYDER JOYCE ANN Zoning:URB Applicant: GEORGE KOEBER AT: 130 HINCKLEY ST Applicant Address: Phone: Insurance: 12 GRASS HILL RD (413) 665-9576 HAYDENVILLEMA01039 ISSUED ON:8/23/04 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP 1 LAYER AND RESHINGLE 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: FeeType: Receipt No: Date Paid: Check No: Amount: Building 8/23/04 0:00:00 2045 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo Department use only _. City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 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 1 30 /I L L (rI Qo I S f- Map Lot Unit . l .1 ha OIL 0I0 Z Zone Overlay District Elm St. District CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: R a-r.4[�. x}-n IL 5 n de e /30 // , Ga_p� Wit., POI-LA. Name n t) Current Mailing Address: . Telephone Signat e 2.2 Authorized Agent: / I ' Name(F nt) Current Mailing Address: /D !(7 j ( 3 G G. if ? 4. Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use Only completed by permit applicant 1. Building STi¢/P vt<'c (a) Building Permit Fee r 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) 1�j/ e(/ O Check Number dogs as--- Q This Section For Official Use Only Building Permit Number: 1E?/9e/Jr-- OZO Date Issued: Signature: Building Commissioner/Inspector of Buildings Date ✓� Section 4. ti/ ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF 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 DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES 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 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ?YES— No IF YES, describe size, type and location: • SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House 0 Addition 0 Replacement Alteration(s) 0 Roofing Windows Or Doors 0 Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other[ ] Brief Description of Proposed / Work: s��/� J cc+J� Alteration of existing bedroom Yes X No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes >( No Plans Attached Roll -Sheet❑ 6 i;:lf.:NO nr41011Sr :and:Or.:additEoil:td: istiiit:terns g:::COMpietelti f#igawfirfg: /7 /{ a. Use of building : One Family X. 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. Mascheck 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 I, ln� .(. ��--r��./ ,as Owner of the subject property hereby authorize 6e0 C I+ to t act on my behalf, in ail mattererelative to work authorized by this building permit application. . Signature f 0 nil Date I, � � , as Owner/Authorized Agent hereby decl that statements and information or e foregoing application are true and accurate,to the best of my knowledge and belief. VVV Signed under the pains and penalties of perjury. y .n Ss Print Name J Signature of Owner/Agent Date SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: ,(� Not Applicable 0 Name of License Holder: Ge�� 5 /� v . �' License Number 56 S 2— Address Expiration Date L / 9- 61E4S3 Fit (/ 11 CY kLAJA.64e �r /241 e/D 3 "l Signature Telephone c P(/ `i(3 FIG ,I / /e) S— Ae ` � t .1 ( 3 65. 9S7G 9.Registered Home Improvement Contractor: Not Applicable 0 Company Name II Registration Number Cr e /(,) C.J bry 1 4 5 Address // Expiration Date 'lhv ✓ Telephone `,4 C ve- vZ 1 • ,v I 6 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 0 No jZ ..................................................... ..................................................... 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-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 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. A. Homeowner Signature ;AI4P?.O 4 D©7: DEPARTMENT OF BUILDING INSPECTIONS 4 = i- / INSPECTOR 212 Main Street • Municipal Building ' 01ti S`'e Northampton, MA 01060 el HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as iris/her construction sup::: Hsor. 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 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 a k I, .k_ &LA_ _ it....it..... understand the above. (Ho e o ner/resident's signatu requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date 1/Z3 in Address of work ' 4 ,�Y, location /j� �c fL� \l7/ � r Petq c_e ik� C9/6 6 Z 4 A� �yE grit of Northampton 1 )- DEPARTMENT OP BUILDING INSPECTIONS 212 Main Street ' Municipal Building \ttar Northampton, Mass. 01060 . 'WORKER'S COMTENSATION INSURANCE AFFIDAVIT I, ---- - ._ . - — — - -- --. O i ce-us«Jpermi ttcc) with 2 pr-islcipal place of business/residence at: _ - - • (phone-) (strc J ivy/statcfap) do hereby certify, under the pains and penalties of perjury, _hal ( ) I am an employer providing the following worker's compensation coverage for 1ny employees wor'ng on this job: - t', cutr-_n= Coor.::.ny) (Pctic.' Numbcr) -- (._:pinion Daie) ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following worker's cot'ni.Jensation policies: (Name of Connac or) (In umncc ColrloanyiPotici Numix ) (-Y_x)tr ttoi Daic) (Name of Contractor) (Ins ranc;. Comoanv/Po!icv Nunl'csr) (t\Tiration Date) (Name of Conn-actor) (Insurane Company/Policy Numb:r) (Expiration Date) • (Name of Contractor) (Insurance Comcany/Policy Number) (Expiration Date) (.tuck sdai ioc,J r'tcG if occc,,ry to aiclu&infor ov oo p.oruLinang to all oorfl-cr_ors) ( ) I am a sole proprietor and have no one working for we. ( ) I am.a home owner performing all the work myself. NOTE:plc;c be ew-zrc t w1^_1c boarnvvnm t+bo ccaploy pe zvnr to do o•_.f,-u-,,m r=�.r�x>c repair wort on a dwell^E,of not tnocc th n ibl>'• a in which the hot-wow-oar resido or oo the grotthda cppurtcn.:rs thc-do c.-r Dot Cetcntly occ it mi to be ocoployc-3,,n.a the w rk c .Lm Act(G L I S2yn 1(5)),npplieuion try•bomeowva far c tics.or permit tr_y cvideocc the Icg1.1 rtanu of en o=ployer under tbn Worlc.or'a Compem.lion Act_ I uo4 tn.ad ch..:a copy of dd.aztcc000i cozy be form rd.d to the Doputmcza of Ioci.arrid',codas&OtSoo of b tooco for ibo eovcrxge vcfif c ijoo e..-ulthe..t L•iltrc to some tovcre a trader reetioo 25A of MOL 152 can lad to the tmpoaIIaoa of criminJ pcnsltict comi sing of a ftoc of up to S 1,500.00 and/or iaxpriloorocztt or up to vac year cod civil pmr.Uo in the form of•Stop Wort Ord r and• fret 0(5100.00 a my alpdast me For a nJ u.c only Permit Number 1.4ap::—_ Lot Signature of Lic nsc/Pcrmiucc Date