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24D-087 (4) f. Once an accessory apartment has been added to a single - family residence or lot, the accessory apartment shall never be enlarged beyond the 900 square feet allowed by this chapter. g. An accessory apartment may not be occupied by more than three people. h. Three off - street parking spaces must be available for use by the owner - occupant(s) and tenants. i. The design and room sizes of the apartment must conform to all applicable standards in the health, building, and other codes. j. Zoning permits issued under this section shall specify that the owner must occupy one of the dwelling units. The zoning permit and the notarized letters required in Subsection B(11) and (12) below must be recorded in the Hampshire County Registry of Deeds or Land Court, as appropriate, in the chain of title to the property, with documentation of the recording provided to the Building Commissioner, prior to the occupancy of the accessory apartment. k. When a structure which has received a permit for an accessory apartment is sold, the new owner(s), if they wish to continue to exercise the permit, must, within 30 days of the sale, submit a notarized letter to the Building Commissioner stating that they will occupy one of the dwelling units on the premises as their primary residence. This statement shall be listed as condition on any permits which are issued under this section. I. Prior to issuance of a permit, the owner(s) must send a notarized letter stating that the owner will occupy one of the dwelling units on the premises as the owner's permanent primary residence, except for bona fide temporary absences. m. Prior to issuance of a permit, a floor plan of 1/4 inch to the foot must be submitted showing the building, including proposed interior and exterior changes to the building. • § 350 - 10.10. Accessory apartments. An accessory apartment, or in -law apartment, is a self- contained housing unit incorporated within a single - family dwelling (not within accessory structures, except with a special permit) that is a subordinate part of the single - family dwelling and complies with the criteria below. 1. The intent of permitting accessory apartments is to: a. Provide older homeowners with a means of obtaining rental income, companionship, security and services, and thereby to enable them to stay more comfortably in homes and neighborhoods they might otherwise be forced to leave; b. Add moderately priced rental units to the housing stock to meet the needs of smaller households and make housing units available to moderate - income households who might otherwise have difficulty finding housing; c. Develop housing units in single - family neighborhoods that are appropriate for households at a variety of stages in their life cycle; d. Protect stability, property values, and the single - family residential character of a neighborhood by ensuring that accessory apartments are installed only in owner - occupied houses; e. To provide housing units for persons with disabilities. 2. The Building Commissioner may issue a zoning permit authorizing the installation and use of an accessory apartment within an existing or new owner - occupied, single - family dwelling and the Zoning Board of Appeals may issue a special permit authorizing the installation and use of an accessory apartment in a detached structure on a single - family home lot only when the following conditions are met: a. The apartment will be a complete, separate housekeeping unit containing both kitchen and bath. b. Only one accessory apartment may be created within a single - family house or house lot. c. The owner(s) of the residence in which the accessory unit is created must continue to occupy at least one of the dwelling units as their primary residence. The zoning permit or special permit for the accessory apartment automatically lapses if the owner no longer occupies one of the dwelling units. d. Any new outside entrance to serve an accessory apartment shall be located on the side or in the rear of the building. e. The gross floor area of an accessory apartment (including any additions) shall not be greater than 900 square feet. 10. Do any signs exist on the property? YES NO IF YES, describe size, type and location: Are there any proposed changes to or additions of signs intended for the property? YES NO IF YES, describe size, type and location: 11. Will the construction activity disturb (clearing, grading, excavation, or filling) o_ v�r 1 acre or is it part of a common plan of development that will disturb over 1 acre? YES NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. 12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION This column reserved for use by the Building _ Department EXISTING PROPOSED REQUIRED BY ZONING Lot Size 75 2 -t a (10 • Frontage X 02 I $ 3 6 r1 0 G 7,5 ZECD Setbacks Front 7� Side L: R: L: R: L: S R: ! s Rear zo Building Height Building Square Footage Open Space: (tot area minus building Et paved 30 parking a # of Parking Spaces 5 \ l # of Loading Docks ) \, Fill: N) (volume It location) `\ 13. Certification: I hereby certify that the information contained herein is true and accurate to the best of my knowledge. 792.0 5 F /01/0 Applicant's -O?g Date: pplicant s NOTE: Issuance of a zoning permit does not relieve an applicant's burden to comply with all zoning requirements and obtain all required permits from the Board of Health, Conservation Commission, Historic and Architectural Boards, Department of Public Works and other applicable permit granting authorities. W :\Documents \FORMS\ original\ Building- lnspector\Zoning- Permit - Application - passive.doc 8/4/2004 i r ' E ��i 1 -� i MAY 1 3 2010 File NoX 1 /0Q. I PERMIT, .P .�'LICATL N (1o.2) �r• Please type.or -print all information and return this form to the Building - - -- - Inspector's Office with the $i5 filing fee (check or money order) payable to the !/ / �l City of Northampton / / 1. Name of Applicant: 1 t l.. 1 DA .> -/L C a- , f �- A / / GZ/n Ct Address: 6C ADCT`-i�7 A `t elephone: 1-- I) 3 - c 7 — 2. Owner of Property: . L • I ' ( I _ I I_ ‘ 7 t . i Address: i L_ G_ `..' - p Lj) ) a�Z.s .Z �-)1. � _ - iI/.1. ,/� ,I Tele hone: 3. Status of Applicant: Owner Contract Purchaser Lessee (Other (� All �Q�,Q c �, OP 4. Job Location: � -- ,L. >- - Ai . I �"' l i Parcel Id:: Zonis 1 Ya' # Parcel# , . ._ 10Emiimo District gy. In Eim:Street.Distnct In Central Busaness District (TO 3 F1.L .ED :I I*} BY THE BUIL'( I NG DEP;#RTMEt T)... , , . 5. Existing Use of Structure /Property: ra /Yl.tj A 6. Description f Proposed Us Work /Project /Occupation: (Use additional sheets if necessary): 1E 1. _ _ C vc // - o04 cl-hp c o Ire Q ;� 7. Att Puns: Sketch Pla Site Plan Engineered /Surveyed Plans 'oo7L f 8. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO (DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and /or Document # 9.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: (Form Continues On Other Side) W: \Documents \FORMS \original\ Building - Inspector\Zoning - Permit - Application- Passive.doc 8/4/2004 File # MP- 2010 -0081 APPLICANT /CONTACT PERSON INCHARDI NINA ADDRESS/PHONE 50 NORTH ST (413) 275 -7115 0 PROPERTY ""t� , THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM ILLED OUT ee Building Permit Filled out Fee Paid Tvpeof Construction: ZPA - 2 FAMILY New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan A CCC S $''Q" l f Fl e r?W't_ - P( 3,50 Po 5 18 L THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRE,SE ED: Approved L./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* V 3;"0 A 1TAG1 / 2 PACK 5 J 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 .1/3// 0 i 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 the Office of Planning & Development for more information. 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/footines (before backfdl) 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 jermits 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 • N h 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 Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents • .--x= f Office of Investigations • • = 600 Washington Street Boston, MA 02111 wwN ,massgov /dim • - Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information , Please Print Legibly Name ( Business /Organza: on/Individual):. D A P! t L ►'7 E `i r p / S • • Address: 15 0 1 W E S i N A T p Ta,-► RD City/State/Zip: F Lco P J 1 G E O I 0 Z Phone. #: � ' S 1 Are you an employer? Check the appropriate box:. Type of project (required): I 1.0 I am a 9mP loyer with 4.. 0 I am a general contractor and I y 6_0 New construction —__- * have hired-the- sub-contractors — 2._ __ loycees (foil and/oi part fime�: I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling . These sub= contractors -have— ship and have. no employees 8. [] Demolition wor ca 3' employees and have workers' [No workersfor 'me . :compin an . insurance comp. insurance.: 9. 0 Building addition requ 5. 0 We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their . 11.0 Plumbing repairs or additions 3.0 I am a homeowner doing all work • myself [No workers' comp. right of exemption per MGL 12.0 • . of repairs • insurance required.] t • c. 152, §1 (4), and we have no employees. [No workers' 13. Fl Other x► T CA E A D5 comp. insurance required} `Any applicant -that checks box #1 must also iM out the section below showing their worioers' coition policy information. t Homeowners who submit this affidavit indira++ng 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. Effie 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: I A Policy # or Self-ins. Lic. #: Expiration Date: Job Site Address: City /Stair/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 51,500.00 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. Be advised that a copy of this statement may be forwarded to the Office of Investieations of the DIA for insurance coverage verification. I do: hereby certify un a pains and penalties of pedury that the information provided above is true and correct — Signature: 7 7" D ate• 7 1 Phone 0: 0 1 t i � � Official use only. Do not write in this area, to be completed by city or town 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 6.Other '' • Contact Person: Phone #: • SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: - I Not Applicablf ❑ Name of License Holder : !J f P 6 v i i I-I v ( 0,45/114 License Number I ,5o1 W fA/•PT O. 5 /2,a /,z, Address Expiration Dat 5 0- 1 6 1 Signature Telephone ` .w'atS r f6 a ..,. / a s . 4 Not Applicable ❑ 16 015 Company Name Registration Number A 14 1EL , HE w ir i S 1 0 /2,6/11 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 VV . No ❑ 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. Homeowner Signature I\ SECTION 5- DESCRIPTION. OF PROPOSED WORK (check all a)plicable) 1 New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [a] Decks [CI Siding [0] Other [o] Brief Description of Proposed L A u t I� i i (P & J Work: CA i . 5 r C - �C Alteration of existing bedroom Yes No Adding new bedroom Yes ✓ No Attached Narrative Renovating unfinished basement Yes ✓ No Plans Attached Roll - Sheet a. Use of building : One Family Two Family Other 1V / 'A 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 I, Qj C , 'I t , as Owner of the subject property i l hereby authorize L t'� fr , to act on my beh I matters relative to work authorized by this building permit application. / e Signzr ;'ek ner Date 1 / €' I,! , as Owner /Authorized 'Agen ereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge elief. Signed under the pains and penalties of perjury. D iJl L W /INS Print Name 7 6 tj Signature of Own= /Agent Date i .. 4 Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplet: Information , Existing Proposed Required by Z tiing 4 o i This column to .: illed "n by Building Depaitu ∎it _ 3 .... . _ - , - i-;,' , , , ' .. •f .1 I Lot Size 1 4 I. wi.,.n r. i Frontage I 11 1 Setbacks Front 1 Eii 13 Side L:f R:-J L:1i R:i 1 Rear 1 1 1 1 Building Height 1 1 1 I Bldg. Square Footage I 1 I % I 1 I ( F 3 __Open Space Footage %- _ __ - - -- (Lot area minus bldg & paved EE = i I parking) # of Parking Spaces :_. Fill: a (volume & Location) A. Has a Special Permit /Variance /Findin ver been issued for /on the site? NO 0 DONT KNOW YES 0 1 IF YES, date issued: 1 IF YES: Was the permit recorded at the Reg'stry of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book Page 1 and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: i ; C. Do any signs exist on the property? YES 0 NO O IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO e -7 IF YES, describe size, type and location: 1 E. Will the construction activity disturb (clearing, grading, ex ation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ' City of Northampton b 4 � L : uilding Department �" � � ° ' 212 Main Street $�` Room 100 ,ti � oFeuacwor+e�ec. hampton, MA 01060 ', i : ;I � -, l �� i ,!,ills .....d l•.. . ^«nr,E — - 587 -1240 Fax 413 - 587 -1272 �, :,) �, � -; � a APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION :1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office � / Q �- y � �" �Mp � ��� k � ' L�rt � � � 'Unit ,cp 1-" F ,,, r , k .. .t € i - 9. Z 1 t " ' Qye p la lar �x �Etfl7fxtifct ... -, C B District SECTION -2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: k r -- p k � Si� cx 1 Name (Print) Current Mailing Addres s r - Telephone Signature 2.2 A horized Agent: VOL). � � (1 � � 7 � 1 AI i 6 L 1- i& '"'i l W J T 1n r P-.D Name Current Mailing Address: --�. J z ®6 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building l 4 c) 0 0 ,--. (a) Btiilding'Permlt Fee r 2. Electrical (b) :Estimated Total Cost af '' Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) I 0 I o 0 Check Number 8 � 1$ (00 This Section For Official ;Use Only Date Building Permit Number Issued: Signature: Building ; Commissioner /Inspector.of Buildings Date File # BP- 2012 -0008 , APPLICANT /CONTACT PERSON DANIEL HEWINS ADDRESS/PHONE 1504 WESTHAMPTON RD FLORENCE (413) 582 -9929 PROPERTY LOCATION 50 NORTH ST MAP 24D PARCEL 087 001 ZONE URC(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out p76`r &O Fee Paid (j 1S Typeof Construction: REPLACE KITCHEN CABINETS & COUNTERS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 049714 3 sets of Plans / Plot Plan THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO PRESENTED: A pproved 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 C::: /W 7/6 ti 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. 50 NORTH ST BP- 2012 -0008 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 087 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- 2012 -0008 Project # JS- 2012 - 000013 Est. Cost: $10000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: DANIEL HEWINS 049714 Lot Size(sq. ft.): 7927.92 Owner: PAROT BRIGITTE Zoning: URC(100)/ Applicant: DANIEL H EW I N S AT: 50 NORTH ST Applicant Address: Phone: Insurance: 1504 WESTHAMPTON RD (413) 582 -9929 FLORENCEMA01062 ISSUED ON: 7/6/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE KITCHEN CABINETS & COUNTERS 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: Date Paid: Amount: Building 7/6/2011 0:00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner 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 ,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 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 Date Address of work location 1 1 . s ' • The Commonwealth of Massachusetts Department of Industrial Accidents - ,• , • Office of Investigation . • • .=.- i= v. r; =111167-z. • 600 Washington Street "Zrr.al-- Z Boston, MA 02111 --.. =:-:y - .., , . www.mass.gov/dia • . • • . -.,....... • .1. • : ...:. -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers • - . ,.. Applicant Information . Please Print Legibly Name (BusinesganitationfIndividual): C U. 2 f t2IJ (2, )(-/ • . ,.. -i ,,,, • !. •:. - • Address: City/State/Zip: - • _ . • Phone.#: • - . , Are you an employer? Check the appropriatebos: • . Type of project (required):. / • 1.0 I am a employer with 4• 0 I am general contractor and I i 6. 0 New corsinietion , have hired the sub-contractors employees (full and/or part-time).* listed on the:attached sheet: 7. 0 Remodeling 24I ani a Sole proprietor or partner- These sub-Contractors have . ship an have nu employees -8. 0 Deniolition • . - worlcing forme m any capacity egAiloyec workers ' . - -• ... -; • rtiffethea.clitidii [140. workqrs' camp-. ixsuiance- io.nllesciric repairs or additions required.] .. . . 5. 0 We are a corporation and its 3.Q I am a homeowner dOing ill work officers haVe - f7teraiSed :their • 11.0 Phi:thing repairs or addition.s . myself [No workers' comp. - . right Of exemP per MGL 1--1 • . 12.11 Roof repairs c 152 §1(4Y ' and we have no • . insurance required.] f ' . • , ' ' emp L-N wor 13.0 Other c • : . .. . - .- • . " comp. instuance mil:tit-64 : • , . • . .. • . - *Any applicant that clucks box #1: must also till out the section belavishowiag their wodcese compensation policy information: • . " • . '-., . t Homeownera who submit thii affidaYit.hytruiatin' I they are doing all work and then hire outside contractors trust submit anew affidavit indicating such. :contractors that check this box tmistattached an adcfitional sheet showing the name of the subcontractors and scatty/hither-or nottitase-erreities have . .. - employees. If the sub-contraCtorshaie emmloyeen, they must provide their works comp policy number. lam an employer that is pkoviding workers' compensation insurance for 'my employees. Below is the policyandjob site • information. . - • . - Insurance Company Name: • - . • • . . - . • - • Policy # or Self-ins Lic. #: - Expiration Date: - . • : . . . . . . . . Job Site Address: : • • ' . .: City/Stafe/Zip:' -Attach a copy of the workers': compensation policy declaration page *(showing the policy munkret and expiration date). Failure to secure coverage . as teatiiiidiiiiiter Seetibii 152 can lead to the imposition ofriMinaj penalties of a line up to $1,500.00 ancVor out-year inipaiSonni* as well as civil penalties in the form of a STOP wca.3.1c_cappER. and a fine of up to S259.00 a day against the violator Be advised a copy 4 tbis statement maybe ,,forWardediUiticjia'ceiof aet Eekiiiaz -- i - iiYieilIcni. . - : _ . . - 1_ - - .7.7::=::::.„ - _ , __,. __ .._ . fitei4 :=6 under the painsand penali ofperjrayiltai infOrmatiOnprov idev.te._cifidiarract ' i. -S ,Si Li. .tin / ' Ill • li 0 41.4. i . . ' - : . . ■ ate- • • . a • • • Phone #: • " ' . • - ' ' . - Official use only. Do not write izi this aira, to be completed by city Or town ell el& City or Town: Perxrdt/License # Issuing Authority (circle one): . .- ' ,_... . • = :1. Beard of Health 2. Building Department 3. City/Town Clerk 4. ElectricalInspector 5. Plumbing Inspector 6. Other . Contact Person: • . Phone #: . • . • _ , SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: ^ Not Applicable ❑ Name of License Holder : CU I (S E A (-N � �+ n,(� 1 / 1 9 9 3 6 License umber i s CA Ft( LA— ( a - Address Expiration D to LC V Er, Tc I f■A 6 Q io C 3 C° ( Signature Telephone -4 8r> Reaistit ltorn(�.impq�rtnetti0iintraax A `` .. a. x_nY. _ Not Applicable ❑ 159'74 ( Company Name . Registration Number 5 /27J/ 7■ Address Expira ion D e 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" 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. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing a Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs ID] Decks [EJ Siding [0] Other [0] Brief Description of Proposed Work: f« FcAct PO(LQkk (OO Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet sa :tf***itiat>fs atid4e d itidi to c tidi iTiii om eihifaif w hip: 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 constru ' n. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Wooastovs Number of each g. Energy Conservation Compliance. asscheck 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 rl 6^e e `v , as Owner of the subject property / hereby authorize CL'ti r his 3C4 i^ vi to act on y behalf, in all matters relative to work authorized by t fiis building permit ap lication. 4,14.4--) C-C-4-,..--y Signature of Owner Date I , C a PAS 6 4 ruv1 G , 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. Cur.:1is 13ACA1 AP``7 Print Name -, Eity i (1 Signature of Owner /Agent 0 to Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Income to lryormatio . , -,. _ n Existing Proposed Required Zojtng This colum o be lled in,b` / / Building D artn nt w e AY ' m , tF Lot Size `_._..�._.� I . ..mm E _.� _. i . '�>. . �' � . r ° � i I ! 1 Frontage _ ., l Setbacks Front I ( 1 ' Side L ., .o R : 1 ) L _ R:I Rear I I I ° - a Building Height '_ Bldg. Square Footage 11____J [ 1 0 4 »' 1-1 f I Open Space Footage t % 1 . ,, (Lot area minus bldg & paved 1 , 1 i parking) # of Parking Spaces S , '- --- -'-' :.a� Fill: . a i i (volume & Location) L -\ _ -- ---- A. Has a Special Permit /Variance /Finding been issued for /on the site? NO Q DONT KNOW 0 °4 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 q Page ' ', % and /or Document # B. Does the site contain a brook, body of water or wetlands? NO' :Q DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ,Date Issued: , C. Do any signs exist on the property? YES 0 NO Q 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: ° ' v. E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a coitgion plan that will disturb over 1 acre? YES 0 NO Q IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ity of Northampto RE E1 ; u ilding Department ! ... , -,. _ '', P' 212 Main Street , s g 1;,.. : y ,Z 514 Room 100 l' n. i V J o ampton, MA 01060 :i � . � � 7� � ; ,' ' , "° , i' 3- 17 -1240 Fax 413- 587 -1272 e 1 DE •_ ,- ., ..+�. _ CATION 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: 5 0 I sT E ( Q- /" Ma Lot Unit 0 /�. Z one Overlay District iN o C 111A VA P l6 ts) a N\ A 0 i ©(a Elm St District .. _ CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: 4 t� �, � Name (P �S --�Nc" , ti - '"r 1z n C� / gib (Print) / uC rre t il' Address: t /1 pM eg .T6 ..�0 a ,, C-c-e -/ . Telephone Signature 2.2 Authorized Agent: Cu (2:1 is T.) A V-P RCS) 1c "7 CAVE 1-i ILL r2., Name (Print) Current Mailing Address: --> CI v U2 - � 4 A_AG o f41 t L V(R1TF i ikAik Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant ' O a (a) Building Permit Fee 1. Building r 2. Electrical (b) Estimated Total Cost of _ Construction from (6) 3. Plumbing Budding Perm Fee T , vJ 4. Mechanical (HVAC) `' 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number /o3� Th Sect For Official;, Use Only Date Building Permit Number: Issued: Signature: Building! Commissioner /Inspector of Buildings Date 50 NORTH ST BP-2011-1072 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 087 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: roofing BUILDING PERMIT Permit # BP- 2011 -1072 Project # JS- 2011- 001726 Est. Cost: $2000.00 Fee: $35.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: CURTIS A BARNABY 99366 Lot Size(sq. ft.): 7927.92 Owner: CREELY ANN & BRIGITTE PAROT Zoning: URC(100)/ Applicant: CURTIS A BARNABY AT: 50 NORTH ST Applicant Address: Phone: Insurance: 157 Cave Hill Road (413) 687 - 8876 0 LEVERETTMA01054 ISSUED ON: 6/20/2011 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE PORCH 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: FeeType: Date Paid: Amount: Building 6/20/2011 0:00:00 $35.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner