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24D-307 . - TALLan: - 17 - 1 - &' -1; I ? 1-1 (P-D, 7 12- ,,,,, f 1,3_411,_, ... ) tV „ „-------; . • ;',3z- t.A Vf-t ...- . . , __,___.--,------ ._,..._ - ..,----- „ , I . N. ---------- .., I 1 l i 9,1. ii 1■61[C-1 1 1 1 WALLS 1 t a 1 1 . , i 1-2 et, etaTukcg 10p IA k r: I roAM _ __ __, _____, 1 2_,- Ho clQ., ‘ 1 $ . , . 1 ram ii\(L Otk-g 9-44:15 i -- C-It'W.t EL-00P--- I *"- 11 1 1 1 1, .„..r. 1 1 1 -----:____ i ii OE? ...., , . . 1 1 . i 1 1 I - , A 11 . 1 1 1 1 1 I I t_ I . I I , 1 l 'i .. 5 ..- 1 . GV ig c) — 4- ..., e.,.... i . ,N. ......, ..._ , re I II _,..4. . - ,0• C M.: L V I --41- .-- 1 _ _ _ 1 7, 1 rs't:L_____ ,c_aira ..... ,_.....] . . I .... d .. if tviA . . 1 4 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 insn io �ocess 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 - - - - - -- -- _perrnits-in- conjunction_to -the building permitissued,.. 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. . mate T___- Address of work location 7. The Commonwealth of Massachusetts -- Department of Industrial Accidents _;�_ �•_! f Office ofInvestiaations • is ��= 600 Washington Street l Boston, MA 02111 www.massgov /dia • -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumbers Applicant Information Please Print Legibly Name ( Business /Organization/Individual): 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.. fl I am a general contractor and I 6. D New construction employees (full and/or part- time).* have hired the sub - contractors 2. �' I am a sole proprietor or partner- hied on the attached sheet. 7. 0 Remodeling ship and have. no P'i''Ployees These sub - contractors have. 8. ❑ Denolon worEng for me in an capacity. employees and have workers' Y ca P ac ty. 9. 0 Building addition [No workers' comp. insurance _ comp..msuranre.$ required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3. 0 3 ama emeo-waer� eta =�31 work D ef�s have°gxercis_P,s...their . —L. D Plumli grepairs or additions myself. [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. insurance required }. *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. . Homeowners who submit this affida indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. IContractors 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. If the 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: • Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City /State /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 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 fi of up to $250.00 a day against the violator. 13e advised that a copy of this statement may he forwarded to the OffirA of Investisations of the DIA for insurance coverage verification. _ I do_ hereby_ certify under the pains and penalties of perjury that the information provided ‘ ,o e_i _true_audcorrect.__- _ _ Signature: ; CL /rte` Date: i ( 0 Phone ##: * 7 7 - 'ter. 93 - Official use only. AO not write vi this area; tol e completed bY city or town offieiaL 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 y Contact Person: Phone #: , SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : d 4 4 4.. f S .-- �ki r s ( (-)/ /6 r Lice a Nu ber -IL/ 0- (A(. e - . fry �• , i-i 1 rEfi3O , ( - 3 [ / Q Address Ex ration ate Gar rh� J'{) g l L../ Signature 6 Telephone 9.,Registered Home Improvementton ...,. i, , ,x ,x.:; . Not Applicable ❑ i i . k f0o Company Name Regi trati n Nu ber l ittle q 51 ( 0 Address Exp ration Date G Telephone / 1 1 i— _, 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 Id No ❑ The_current_exemption for_" honieow_ners" 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, ui 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" c ertifies and assumes responsibility for compliance with the State Building Code, City of " ampton erofnances; a - .ni i ,. , - ^ i. - . ,- , s- General-Laws Annotated Homeowner Signature 4 SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ® Roofing ❑ Or Doors 0 Accessory Bldg. EJ Demolition ❑ New Signs [D] Decks [C] Siding [0] Other [0] Brief Work: Description of Proposed l 2 t:rjO1 A1 f VA ,J(• 51. 71 rvxN1 Alteration of existing bedroom Yes 1 No Adding new bedroom Yes V No Attached Narrative Renovating unfinished basement Yes ^7 No Plans Attached Roll - Sheet 6a_ If New holis.e.and or cadditio tto;.existinq h6 inq;�complete the.follo a. Use of building : One Family ( Two Family Other b. Number of rooms in each family uni • umber of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construc 'on. C) Dimensions e. Number of stories? i A. f. Method of heating? 1A) Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. AIIIIL Masscheck Energy Compliance form attached? rJ 0 h. Type of construction kftrt Fk dk,riC i. Is construction within 100 '. 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? V Yes No . I. Septic Tank City Sewer Y Private well City water Supply SECTION 7a!- OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR DUILDING PERMIT f A N 0 v - CALL j i bait W61444 , as Owner of the subject property hereby authorize ~J A . , S / t ii 6 u. to act on my behalf, in all matters relative to work authorized by this building ermi application. j 7 Signature of Owner Date I, (r 1 a / y o ` e i , as Owner /Authorized Agent hereby d that the statements a information on the foregoing application are true and - accurate, to the best of my knowledge and belief. Signed under " pains and penalties of perjury. ilf, till /4 Print Name r Signature of ner/Agent Date 1 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 Building Department Lot Size Frontage Setbacks Front Side Rear Building Height :10-21 J t Bldg. Square Footage 3' % Open Space Footage (Lot area minus bldg & paved parking) 1 # of Parking Spaces Fill: (volume & Location) ' .__ A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO DONT KNOW 0 YES 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 = Page and /or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO 0 IF YES, describe size, type and location: 0 '— rre tie e any proposed c tinges to or a• itions o signs inter ecTfor the 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 © IF YES, then a Northampton Storm Water Management Permit from the DPW is required. r City of Northampton s� o Fet Building Department errttt 212 Main Street 5 *v yaiial�y � Room 100 u + r; 01t � Northampton, MA 01060 phone 413- 587 -1240 Fax 413- 587 -1272 4,„' r� 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 - I4-L$ l D Map Lot Unit Zone Overlay District `EIr:St'District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: f ±�_� i .� I, '� ryt� E 1 t 1 N n x,-1- 5 (D [4) nI 1 1 11 =�' r 1 Z I Name (Print) Current Mailing Address: ......,,.. ._..__.._. Telephone •�� (( ,�, `J 3 Signature "( 2.2 Authorized Agent: 'NAk f "74 afi> STJ t -p L).HAI t �(d� Name (Print) Current Mailing Address: `) /9 /7A4 j'tft. 11 3 z- .—1 ggric13 Signature Telephone SECTION 3- .ESTIMATED CONSTRUCTION. COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building k9- -q (a) Building Permit Fee 2. Electrical ,y"" � 1 t� � (b) Estimated Total Cost of "CC Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) j� ,. ' Check Number j• qr /-1 This Section Fur ifflcialUse Only Date Building Permit Number: Issued: Signature: Building Commissioner /Inspectorof$uildings "" Date r i File # BP- 2010 -0734 APPLICANT /CONTACT PERSON JAMES PHANEUF ADDRESS /PHONE 74 Old Stage Rd W HATFIELD (413) 247 -9993 PROPERTY LOCATION 18 HILLSIDE RD MAP 24D PARCEL 307 001 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 AU/ Pip Fee Paid Typeof Construction: RENOVATE 3 SEASON ROOM New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 011632 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 24 1P� 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. BP- 2010 -0734 GS #: COMMONWEALTH OF MASSACHUSETTS s 4*2 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 -0734 Proiect # JS- 2010 - 001089 Est. Cost: $36000.00 Fee: $180.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JAMES PHANEUF 011632 Lot Size(sq. ft.): 21257.28 Owner: HEHN BOYD T & ANNE L TALLENT Zoning: URA(100)/ Applicant: JAMES PHANEUF AT: 18 HILLSIDE RD Applicant Address: Phone: Insurance: 74 Old Stage Rd (413) 247 -9993 W HATFIELDMA01088 ISSUED ON:2/22/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: RENOVATE 3 SEASON ROOM 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 2/22/2010 0:00:00 $180.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo