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23A-031 (3) • i ' > f ar ,„ '"'a r a� ,�` ". . — k � :iii .. • �.. 'tea $i , • �a / ` x1 �� `, fi -‘k,,.-•, .. :.. -.,: - ....-. -. -.. " „: # - '' ' -', : ,-':',':*,. . ,..: ' , ... , ;: :: ; - 1'• ; • ' ''; . ,•••.1.., , a ; , - . ;- : -,"[ ; '4 2 ,... 4 V ����� � , '� �� '0,-'• �+„��" � biz a �`' � • ��.> s w y x � '''x« r r f • dnuill saiw 1 --7.7" ....- '' !pill°, 1 rk 4I .:, .,- ok - . - .b,,,,,H*' " y ax� V 1 i n J °V e i 1 04 57111-1 ' i • illa I € al mas i OR RP j par Ili lir tGli • \ i ern f) Ca'll,.1 '''-' r ( .....„........, - ---- ,, 9 ,,,•-• 1 ., I : t ; , •,,.. ■ i ' , . - r ------ - -,, ,... . : .,,,,,,,_ r , / . . . , - X .,--,, •i 1 , . . ,, h)(i i• . i s)11 . , ,../ f , ' ., /.---._ 1,, -._ ,. ,. ..4 . • r ... 1 '-.. . -. A •;"i -- --,..- / -, - , ,, . ,• , . Ni•_, ,, / ___ ... ::., I ,...., .. . „ . : .,.. 1\.. , - \ 1ell i a -.4.,„ , 11 -=-• '' , - -r.i , I - t • . i --...--:. ,, ›( ci btilig volt — , -A-- ,, i ..-, . . , ..... _,... .„. . c ..., .. 0 - . 2 M 0 CO L -17 o m 0 ,,, _ ---- - alli - 1St 1 ,...,, iss c.--..,c_s•I‘\7,c-c"‘ L------- 9 te 0 --i ii Li. C c''')\-' '\\ :..'`.\_----• 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 hone owner exemption, 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 occunancv 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 i ermits 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 1, -- , : = " understand the above. e owner /resident's signature requ • ng exemption) I will call to schedule all required build' . _ inspections necessary for the building permit issued to Date Address of wo location , 7 a. t . . . . .\ The Commonwealth ofMassachuse Department of Industrial ACcidents Office of InVestigationS 600 Washington Street 11 111= --- / Boston, MA 02111 : • . . -.=..-:- www.mass.gov/dia , • ' -Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers 7 Applicant Information - Please Print LeRiblv • ::',: . Name (Businesi/Organiiation/IndiviOng1): , • • • ! • • . Address: ,. • - City/State/Zip: - . Phone.#: • - . . Are you an employer? Check the appropriatebox: • Type of project (required): " • 1.0 I am a employer with 4.. 0 I am a general contractor and I ' 6. 0 New construction have hired the sub-contractors employees (full ancVor part-time). • 2 ,KTI I aril a Sole proprietor or partner- lister' on the:attached sheet: 7. 0 RemOdeling ''.ndh These sub-contractors have .8. 0 DeMolition . . • . . . ave no employees • working forme m any capacity . emk workers' 1 -9.: Er-B-f . rige wOrkeirs" comp-. insurance 10.0-Electrical repairs or additions , . . 5. 0 We are a corpoi tion and its 3. 0 I am a homeowner doing all work officers lia•VetcerCisei their 11.0 Plumbing repairs or additions myself [No workers' comp. • deg Of exemption per MGL r-7 . . 12.11 Roof repairs . • ' • insurance rewired.] t • • , . 152, § 1(4), and we have no • . einployees. [No workers' 1 4- 0 6 ther r • ' . - • . • Comp insurance reqUired.j. . . • - - : . *My applicant-that checks box #I must also fill out the section below showing theirieorkets' compensation policy informatitht t Homeownern who submit thii affick:vitincriciaiin' i they are doing all wait and then hire outside coati-tors =at submit a new affidavit indicating such. :contractors that check this box must attached an additional sheet showing the name of the suh-contractors and state whether or notthase entities have . • employees. If the sub-contraCtorshaVe cmployeet, they mustprovide their wOrkets' comp. policy number. , 1 run an employer that is providing workers' compensation insurance for my einplOyees. Below is the policyandjob site information. . I insurance Company Isame: Q ‘-)(' _-: ;,1 - R.. i') ( • - 1 Lic or Se PO licy # lf-ms . #: ‘r-. — S`LS f- 3 .:._., 1.r") , ` 1-(-. --) t i Expiration Date: - 1 ')..(/ i / . .( . (- t Job Site Address : ( -j( '' :r , 'S ' ., _ 1 ')-( . e ''.-- ON . City/State/ZiP:' . \ .. ,':-_, •:-> - • Attach a copy of the worker?' compensation pokey declaration page the polic-y nurober and date). . . . . Failure to secure coverage as regaled iiticir S6ttrOh 152 can lead to the iiiii5Oiiii6ii Of'Ziniiiiiii:41es of a fine lip to S1,500.00 and/or one-year imprisonmen4 as well as civil penalties in the form of a STOP WORK-QRDER and a fine of up to S250.00 a day against dieViolatcir. Be adviSecl that a copyOf this statement maybe fO o rwarded to the:OfriCeiof :_; - ave -- s a tiialioOf thi'DIA — foi l iiiiti e'Ciiiiii t _ ---T ' 7:_ _.:"„ l :,`,.. \ firo7iiiii_fty1eii-if:fifii ii4.; ti i p '3 T ;iii;LOe;ii ,11 ; :iitai ii;i:firirriliin;r;i;ilirii0 ,,:./ ,,, - ,.. . Si tare: 7:.)., -....! ./. . --.' i - • • ate- ..: / • . . . , . . Phone 4: ';Th, C.,-:- C 4- (0 c7... . - s. ' . . . - - • • . . - OffiCial use only. Do not write in this area, to be completed by city Or to wnOfficitil . . City or Town: • "- Permit/License # ' I Authority (circle one): .. . .1. Beard of Health 2. Building Department 3. City/Town Clerk 4. Electrical inspector 5. Plumbing Inspector 1 6. Other . Contact Person: Phone #: - • r SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: \ Not Applicable ❑ Name of License Holder : > "''� `� ` V. \\ 1 "' " ` ( 4 (0 lb License Numbe Address Expiration Date // el Sicfnature Telephone 9:`Rectlstere ll.Ffntnr Irttprovemen ' Gain racttor� yi a r ,�' 77, :zezittga Not Applicable ❑ \fin. a' ,� > ;r ;� \ C g� ` ;- Company Name Registration Nu ber 9 ( Address Expiration Date '04 - ' k ° <? Cw(('71c -� 'a Telephone 1 — 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" was extende o include Owner - occupied Dwellings of one (1) 0 0(2) families and to allow such homeowner to engage an individual for ' e who does not possess a license, provided t t the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5. Definition of Homeowner: Person (s) who own a parcel of lan • on which he /she resides or inte • to reside, on which there is, or is intended to be, a one or two family dwelling, attached or ' • ached structures access. • to such use and/ or farm structures. A person who constructs more than one home in a two ear period sh of be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acce.table • e 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 be req ' ed 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 (W• ers' Compensation) and ■ apter 153 (Liability of Employers to Employees for injuries not resulting in Death) of Massachusetts General Laws An .fated, you may be liable for person(s) you hire to perform work for you under this - rmit. The undersigned "homeowner" certifie . nd assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State . • ocal Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature 1 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing IR Or Doors 0 Accesso Bldg. r De olition ❑ New Signs [0] Decks [p Siding [0] Other [0] �fDes Bricripti n fProp c osed, r . r . `—�, r y T �� I �•C_� �p\.r.i Si \I, `.'�.,i �kk( -. work: 11 � .,.. , 1c ...1°, 1', Q\+�, - s r\,---j 1 1 v ..( 1 0 \' ;� � l , 'ril>> S 3 i _� � . 'C Q,riNN 9 i'N .. 3'.: c Alteration of existing bedroom Yes )�' No Adding new bedroom Yes Y No ; Attached Narrative Renovating unfinished basement Yes )G No Plans Attached Roll - Sheet sa. tite , to ilid*r dtl I t rti rcrii iir a cr eili a tatiga: a. Use of building : One Family Two Family Other b. Number of rooms in e- • family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new constru i• • aimensions e. Number of stories? f. Method of heating? i = •laces or Woodstoves Number of each g. Energy Conservation Compliance. Masschec nergy Compliance form attached? h. Type of construction i. Is construction within 100 ft. • , etlands? Yes No. Is construction withi 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 c-- `� 1 as Owner of the subject C ' '' ) C, bft , ) CV\ N S . (;\ \\ property hereby authorize to act on my behalf, in all ma f ers relit to worjs aythori by this uilding permit appli tion./ Signature ofi Owner / Date ( I, c--`-')W, 1 c, f 1 '�.\,;, l , 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 „..'"/ 7, ./ 7' - > Y4f - A ' .- - -/ - P/ ".' /V Signature of Owner /Agent Date 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 3 Building Del lartment +� —"' m Lot Size .\ ' _ _ l Frontage 1 i 3 Setbacks Front \(----1 Side L: ` R: — 1 L.1 a R:? I t i x 1 Rear 1 Building Height , i [_ _ r , Bldg. Square Footage 1 I 1 l % I Lili"" Open Space Footage 0 0 1- 7 (Lot area minus bldg & paved L..... parking) # of Parking Spaces - Fill: __/ ,____ ___ ,�. . . _ (volume & Location) 1 r A. Has a Special Permit /Variance /Finding ever bee ' issued for /on the site? NO 0 DONT KNOW 0 \ ES 0 2 IF YES, date issued:; 1 IF YES: Was the permit recorded at the Registry of Deeds. NO 0 DONT KNOW 0 YES Q IF YES: enter Book Page i and /or Document # B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conserv. ion Commission? Needs to be obtained 0 Obtained , Dat Issued C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0 IF YES, describe size, type and location: 1 , 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 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. . . • ' 4 ,,,.,.....- q , ,,, , 47,- - 1,..,_ ",,,,0 ,.-_ , 4,0 Ac s.,:,,P,,-„,,,q,,,:„.v-,Ti, ' '-'" \ : -::: ‘.-, rrk l igi ; .W', 44 4.41. si.4. .''. '1 ' 4 - ',Na' 0 1 , iv: . - - City of Northampton .... .11i-actiku,t:44, , cov ‘--‘ Building Department AA04 212 Main Street ''' °.:,t4faaVW,,t1,f,atr.”44:fgs.'Atitk Pia st rION Room 100 '' o ampton, MA 01060 ,15'.:431:a'iit-An!f4,71,!;'-u-:-, ',.:',,°t45P1F45*,7r7,7azni.:4,0,t'nf - - --- : 15f : . :7-1240 Fax 413-587-1272 :. !CATION 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 comPieted by office 6 Cr'c1/4 dc 31' Map Lot Unit Zone ' - - OverlaYDIstrict Erni St. DistOct ' CB District SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: e --.. -----. \ 73 (----) (..._).‘ kl . , i Name (Print) j Current Mailing Address: 'I Telephone Sighature 2.2 Authorized Aaent: :„...... c? ,,,, k V Name (Print) / Current Mailing Address: _ Signature Telephone SECTION 3- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building 1 Itt) ' (a) Building Permit Fee 2. Electrical C' '% k.) (b) b ) E C s o ( i n n ; t u e ct d i o tfarol Cost from (6) of • 3. Plumbing f ift%Itaii IL`•4 ' - ' Building Permit Fee t t I 4. Mechanical (HVAC) 5. Fire Protection 06V2 6. Total=(1+2+3+4+5) 2,7_,O o () Check Number / This Section For Official Use Only Date Building Permit Number: Issued: Signature: Building Commissioner/Inspector of Buildings Date File # BP- 2011 -10153 APPLICANT /CONTACT PERSON HARLOW BUILDERS ADDRESS/PHONE 336 COLES MEADOW RD NORTHAMPTON (413) 586 -0465 PROPERTY LOCATION 67 PARK ST MAP 23A PARCEL 031 001 ZONE GB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /`y *3A Fee Paid /09 Typeof Construction: STRIP & SHINGLE ROOF,REPAIR FOUNDATION,REPLACE. LANDING /STAIRS,REPAIR SILL,FRAME DOORWAY —° 1 &asr 5 # ( 1,4 ION £X(ST I NG F 001 ; R I N t New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 052460 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: i../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 Commission _ Permit DPW Storm Water Management Demolition Delay (. L 7, L/LJ 6 717/1 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. 67 PARK ST BP- 2011 -1063 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 23A - 031 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: renovation BUILDING PERMIT Permit # BP- 2011 -1063 Project # JS- 2011- 001713 Est. Cost: $22000.00 Fee: $132.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HARLOW BUILDERS 052460 Lot Size(sq. ft.): 17293.32 Owner: HARLOW SCOTT Zoning: GB(100)/ Applicant: HARLOW BUILDERS AT: 67 PARK ST Applicant Address: Phone: Insurance: 336 COLES MEADOW RD (413) 586 -0465 Workers Compensation NORTHAMPTONMAO1060 ISSUED ON:6/17/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF,REPAIR FOUNDATION,REPLACE LANDING /STAIRS,REPAIR SILL,FRAME DOORWAY - MUST STAY WITHIN EXISTING FOOTPRINT 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: 6° 7/P 073d- FeeType: D t o Paid: Amount: 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner