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24D-167 . <- \,.' . , , . . ( \sj 4 1. ' ' (j_ - _ • :',.\_ .........____..................... . t v, a i It w .i4 1 N j-ir ,a- ' v it : X11 -hxz �IJJ 1 1 ' Nie eri 0 0 L \ N. 1 3 ./. , d 4 7 : 1; : - r Sid' 01-, 0414 1.01 ni 0/ 1A/P3 . ? f ►ZI 4141 ©s vs .- t — : 'An w-V0a -00014 inry 1.49W7 y<, cswo I.Ncrvd --31,e _ 1 _____.1.....---.-----. --....I . 1.....-----__ , i . 4 vo ;... � 1417W 712l/1 `d %'' Z S — 4. r (,�aNUO) �� . 2, 1 IM �I� ( &ob �W�j I a Uc�l U N �� ' ' , -WY • • 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 0 21,60A -- l _S understand the above. (Home owner /residents signature requesting exemption) � b''n 9 g P ) I will call to schedule all required building inspections necessary for the building permit issued to me. Date 4/fiie / 26 Address of work location ` , Q.s-1 ilzyv O/d 6 • • . , The Commonwealth of Massachusetts Department of Indus Accidents xt . =liii=.— 1^ ' (ri Office of Investigations 1 =-- - 600 Washington Street t - 11= - - i.... --.,:-- Z Boston, MA 02111 - , www.mass 0 , • -b Workers' Compensation Insurance Afftdavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (BusinesS/Organization/Indivirinal): Address: ,.. • City/State/Zip: - Phone #: • , Are you an employer? Check the appropriate box: Type of project (required): / 1. 0 I am a employer with 4. 0 I am a general contractor and I 6. 0 New CO on have hired the sub-contractors employees (full and/or part-time).* listed on the attached sheet. 7. 0 Remodeling 2_0 I am a sole proprietor or partner- These b-con sutractors have ship and have D.Q=ployees 8. 0 Demolition emplo_yecsand have workers' • working for me in any c.apacity. 9. 0 Building addition _ comp.instirworm 1 - [No workers' eorrip. insurance 10.0 Electric:al repairs or adaions ecluired.1 ' 5. 0 We are a corporation and its 3. ■ I am a homeowner doing all work officers have4xercised their • t 11.0 Plumbing repairs or additions uyself [No workers' COMp. right of exemption per MGL 12.0 Roof repairs . - insurance required.] t • c. 152, §1(4), and we have no employees. [No workers' 13.0 Other ' comp. insirmnce required.] ' *Any applicant that checks box #1 mist also MI out the section below showing their workers compensation policy infonnation. - - t Homeowners who submit this affidaVit inclicating they are doing aIl work and then hire outside contractors must submit anew affidavit indicating such. . 1 C.ontractors that check this box must attached an additional sheet showing the name of the sub-contractors and gam wheeler or not those entities have employees If the sub-contractors have employees, they must pro their' workers' comp policy number. lam an employer that is providing workers c ompensati.on insurance for my employees. Below is the policy and job site information. • Insurance Company Name: • • • . Policy # or Self-ins. Lic. #: Expiration Date: Job Site Address: City/Sta&'Zip:' • ' - . Attach a copy of the workers' compensation policy declaration page (showing the policy number and expi date). . .... Failure to sec-iire coverage . is required inider Sectiiii1 Of MGL c. 152 can lead to the iiipOsitiori ofdiminal Penalties of a fine up to S1,500.00 and/or one-year imprisonme4 as well as civil penalties in the form of a STOP WORK-ORDE:R and a fine of up to S250.00 a day against die violator. Be advised a copy of this statement may be forwarded to the Office of HiesileitiOns &the DIA for hisurance 6tiviraie iieiifiCiiiiin. .: ----- 77.7. ---- 7_717 - _ I do Itereky_certi under the ,ains and penalties ofperjuly titat the infornurtion provided ithoveistrue_and_COrrPto Siu. .tui AlIAb.l -al I. All AI • ..4 .. 1 l ate" (--" C dir / 0 7i () Aivii941)1 cel() 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: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone 9..`:R0t1istee tnifi ttE ImtiriavdMlet Bent awa „ i :F ')° lei Not Applicable ❑ Company Name Registration Number 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 ❑ eninn 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 Zo ing Laws and State of 1' General Laws Annotated. Homeowner Signature � \,1/t SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. Demolition ❑ New Signs [0] Decks All Siding [0] Other [0] Brief Description o Prop ems r f / j A Sens ^ ?d r� 9cj 2p o1 1- Work: d= ( f�C 4' 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 ot/ Two Family Other b. Number of rooms in each family unit: 7 Number of Bathrooms �--- c. Is there a garage attached? /2 a d. Proposed Square footage of new construction. / / ( • ZJ C q 1 Q u Dimensions (> "kJ e. Number of stories? _ 1 f. Method of heating? f} h e v Fireplaces or Woodstoves Number of each "or g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction y )oOC J -` 1 i. Is construction within 100 ft. of wetlands? Yes ` /No. Is construction within 100 yr. floodplain Yes j. Depth of basement or cellar floor below finished grade / k. Will building conform to the Building and Zoning regulations? 1/' _ Yes No . 1. 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 , 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. Signature of Owner Date / ( , 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 andpenalties of perjury. A L t D 19 L_.6. \&i Print Nati% Signature of ner /Agent Date A Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed I Required by Zoning This column to be filled in by Building Department Lot Size 3 • ` 6 ? (C 1 � P _ E 1 Frontage r ( > e:=7----- Setbacks Front = En ? Side LA I R:! I L:I J R:' I Rear I 1 = I i i Building Height � i I Bldg. Square Footage 1 ! [ 1 % (n 1 1 Ell Open Space Footage l % (Lot area minus bldg & paved j :_ parking) , # of Parking Spaces — I `-- ' Fill: (volume & Location) 1 , A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO i%i 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 Pagel = and /or Document # B. Does the site contain a brook, body of water or wetlands? NO Vi 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 ,Date Issued: C. Do any signs exist on the property? YES Q NO 9/ IF YES, describe size, type and location: r D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO R . IF YES, describe size, type and location: E. Will the construction activity disturb (clearing, grading, ex vation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES Q NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. r , City. of Northampton , Build g Department ,W r % . > 212 ain Street oom 100 No hampton, MA 01060 phone 413- 587 -1240 Fax 413- 587 -1272 API?LICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 ProoertvAddress: This section to be completed by office m Map Lot Unit ( ?/7 Y 7 " 7 Zone Overlay District Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: � t ers. LtW1S 4111 i1i so) (M r Name (Punt) Current M it ddregs: / `7 6 2 6 7 ry ` LJ Telephone Signature 2.2 Authorized Argent: Name (Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit 1. Building 1 ()CC O (a) Building Permit Fee 2. Electrical V (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection a` � V 15 � n .- 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 File # BP- 2010 -1163 APPLICANT /CONTACT PERSON DWIGHT WILLIAM & ALIDA LEWIS ADDRESS/PHONE 39 MYRTLE ST NORTHAMPTON (413) 262 -6710 Q PROPERTY LOCATION 39 MYRTLE ST MAP 24D PARCEL 167 001 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 er, Fee Paid 11 ► ' Typeof Construction: CONSTRUCT 8'9" X 12'5" DECK W/ROOF TO FRONT OF GARAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: (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 Signature of Building Of icial 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. 39 MYRTLE ST ` x BP- 2010 -1163 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 24D - 167 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 -1163 Project # JS- 2010- 001698 Est. Cost: $1000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft): 6882.48 Owner: DWIGHT WILLIAM & ALIDA LEWIS Lining: :MC( 1001r Apnlicant: J DWIGHT WILLIAM & ALIDA LEWIS AT: 39 MYRTLE ST Applicant Address: Phone: Insurance: 39 MYRTLE ST (413) 262 -6710 0 NORTHAMPTONMA01060 ISSUED ON :6/28/2010 0 :00 :00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT 8'9" X 12'5" DECK W /ROOF TO FRONT OF GARAGE POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: ,o c ci-g - j 6 G ,, THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND RE • 1,0N N. 1$ ilvw Certificate of Occupanc /ignature: t&spwc-e- FeeType: Date Paid: Amount: Building 6/28/2010 0:00:00 $50.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo r