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BOOK 3230, PAGE 25
SEE: PLAN BOOK 42, PAGE 13 '
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CHESTNUT STREET
Ito .
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. 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 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
- - - - - --
perrnit&_in_conjunction to_the_buildingpermitissued, _ 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, 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.
Address of work
location
The Commonwealth of Massachusetts
Department of Industrial Accidents
g isirl E Office of Investigations
_
r r _ 600 Washington Street
e ,
• E: =_
Boston, MA 02111
www.mass.gov/dia •
-Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name ( Business /Orgarnzation/Individual): N/ 4Vfl /TS / �1f1"GJ 'aiC
Address: 6 5 41 au. w Pr IA) S 7 -
City /State/Zip: f tt F4) thc-a /i44 d / 0 3 f Phone. #: I I/ 3 - 2 G 45 - 7 a 9
Are you an employer? Check the appropriate box: Type of project (required): /'
1. ®I am a employer with / . 4.. [J I am a general contractor and I
6- [aNew 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. 0 Remodeling
These sub-contractors have. r- -
ship and have no employees b $. [�Henio,ition
for me in any capacity. employees and have workers'
working
Y P ty 9- D Building addition
[No workers' comp. insurance comp- insurance.$
required.] 5. p We are a corporation and its 10 Electrical repairs or additions
3. I am-a- homeowner -duin - G °r Zexcised ir-- --1-1.0 Plumbing repairs or additions
myself [No workers' comp- right of exemption per MGL 12. Roof repairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Oilier
comp. insurance required.}
'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit this affida indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub - contractors and state whether or not those entities have
employees. lithe 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: / SS /9- /611 Z - e....0 VAI S4 /fit --•J ce e,,,
Policy # or Self -ins- Lic #: tADC- -e- 0 D 3 n 1 o / 2 a / d Expiration Date: . ' // d
Job Site Address: GLVF€ $' % P vs, City /State/Zip: * 4- te -4-) log 'VIA di «c Z
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 $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator: Tie advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certify u ' th " , , nd penalties of perjury that the information pr.ovided_above istrue _and correct _ __
Signature:
• Date: V I- / 0
Phone #: 4//3 —" Z 6" — 7
Official use only. Do not write in this area, to be comfkted by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
i Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector _
6. Other - J
Contact Person: Phone #:
SECTION 8 - CONSTRUCTION SERVICES •
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : v 4 S �—' � 64 • v J / 2-
License Number
/>7ecc , Jr+„J S %. hc ypsA J «, X1%14 Dot 7- Z3/2e1,1
Address Expiration Date
/ Z ea — ?v 5 !`
gnatur Telephone
9..Recristeretf +lome4.ltni rovertet tOoritractol a iii i �4_a. 4 z Not Applicable ❑
iss ere/
Company Name Registration Number
5// cr/ Z a t (
Address Expiration Date
Telephone
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 No ❑
The_current_exemption for "homeowners "_ extended to include Owner 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
o ampton eYetnances; a -.: • " • _. , - •:_ • . . sfreneral Laws Annotated.
Homeowner Signature
J
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) [J Roofing
Or Doors ❑
Accessory Bldg. Er Demolition ❑ New Signs [M] Decks [E] Siding DM] Other [C]
Brief Description of Proposed 2�{ )42-6: G c,
Work: 12 &o E1H 5% G , 2EPLAcC (,PH NeL.J
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes c_ No
Plans Attached Roll - Sheet
a'`like Use lid ddn i ct t gditrii4liaus ti iiinfilct .t e f no g:
a. Use of building : One Family 1 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 AG N OR 0 TRACTOR APPLIES FOR BUILDING PERMIT
1, 141 aft
r " -- i ' 4 I A I A , as Owner of the subject
property
herebyauth•rize -.14w ' yrL.J(Z&U
to act on • / • - half, n - 1 • atters relative to work authorized by this building permit application.
.
Signat re o 1 ne Date 1 J
444 /-14-L-J , 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 thy•ains enalties of perjury.
Print Na e / /
Signature of Owner /Agent Date
e
Section 4. ZONING AU 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 2 - 4-14£ S J I
Frontage L. __.__.. _ _._.___ _.._ `
Setbacks Front q s ' 9 a 1 f 1
Side L U1t R:7 5 = L:IT� -6-1 _1 R ��,'' __
Rear -
Building Height t 2- ma
Bldg. Square Footage 13 ab j E ?% Lo t 1 r: i
Open Space Footage %
(Lot area minus bldg & paved i
i
s i
parking)
# of Parking Spaces E 3
Fill: I ........._�.._�. w..,.�w.,._..�� /4/ �n��rc►�gUc -
(volume & Location) a — r . -- ------ ---
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 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 0
IF YES: enter Book 1
i Page; and /or Document # ry
B. Does the site contain a brook, body of water or wetlands? NO - DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued
C. Do any signs exist on the property? YES 0 NO e
IF YES, describe size, type and location:
_- -- — mD: Qre tt a e'any proposed c angel o'�or a loo or signs intenZEd roi die property ? YES 0 NO ---
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 er
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
•
-e ji a t 2
City of Northampton 1; , , ,
Building Department C 14 4 m - 4 ,. * k "
212 Main Street
1, Room 100 r
q r)::.) Northampton, MA 01060
`' phone 413 -587 -1240 Fax 413 - 587 -1272 m - itlit
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
2 Z - FS+ Nom' s i Map Lot Unit
f'C 6 i'F 9 (-- ' Zone Overlay District
, EIm St District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Prin / Current Mailing Address:
�i . ... 'A. „ Telephone
Signature ' '
2.2 Authorized Agent: / • James A. ate.) ,..,,t) 4 o i 7, etAi y y4 ,c) fr. / . c
Name (Print) Current Mailing Address:
�,-�. 4/4 - 2-4 5 76 71
Signature Telephone
SECTION 3 - !MATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building , T (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
z
D srD Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _
6. Total= (1 +2 +3 +4 +5) 4I v Check Number 4 /OC9 J6 Y
This Section For O Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
1 -
r -
Massachusetts - Department of Public Safct■
Board of Building Regulations and Standards
•
'Construction Supervisor License
License: CS 10092,
Restricted to: 00
JAMES C LAWRENCE
85 MOUNTAIN ST
HAYDENVILLE, MA 01039
--4-- - � , *Expiration: 12/23/2011
(,nin inner Tr 10999
4 a
File # BP- 2010 -0838
APPLICANT /CONTACT PERSON JAMES LAWRENCE
ADDRESS/PHONE 85 MOUNTAIN ST HAYDENVILLE (413) 268 -7099
PROPERTY LOCATION 226 CHESTNUT ST
MAP 17A PARCEL 286 001 ZONE URA(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 6 s 3 'Paq+ q-v
Fee Paid �`U(p `C
Typeof Construction: DEMO EXISTING GARAGE & CONSTRUCT 24 X 26 DET GARAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 010092
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
LVF0p.MATION PRESENTED:
oved 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 Commission _ Permit DPW Storm Water Management
Demolition Delay Lif
C7 47 -1/4.( j
Signature of Building Officia 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.
S
4 y
226 CHESTNUT ST BP- 2010 -0838
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A - 286 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- 2010 -0838
Project # JS- 2010 - 001239
Est. Cost: $42000.00
Fee: $124.80 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES LAWRENCE 010092
Lot Size(sg. ft.): 43560.00 Owner: CHESTNUT ST LAND TRUST CIO ROBERT ABUZA
Zoning: URA(100)/ Applicant: JAMES LAWRENCE
AT: 226 CHESTNUT ST
Applicant Address: Phone: Insurance:
85 MOUNTAIN ST (413) 268 -7099 WC
HAYDENVILLEMA01039 ISSUED ON:4/9/2010 0:00:00
TO PERFORM THE FOLLOWING WORK:DEMO EXISTING GARAGE & CONSTRUCT 24 X
26 DET GARAGE
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 St. nature:
FeeType: Date Paid: Amount:
Building 4/9/2010 0:00:00 $124.80
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo