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17C-266 I -rt 4 i i 114 1!1 . ...trr'.I,t let l 1 f 1 1) :)tict .i,lp!o' i tictutzil)tio t 4..0 ii, 111.(1 11. Sett .1:1 .)ltlt>,:>li(lcit i r)trf 111 trt )ttattltstlfl)t! 1)1.lt' K111s c1c1€ `I t }`W %St', - t) '1).1111! t , 1)21ltlr) )< -) h.) :x1, all 7011; ct<) t1t)!U'a1lr.r s', (,,) 1a,11 In :Nit?, 1.1.)1; 1. ii 1() - ' : 4c: ' 11„x1! !c•1(1 ` 1 ill 1)t!t! trF }.,)1) lt 1.!t`. c1. c(rl l ; , .aft)111 a ;i :',11C st�1(1l5tlatl!! €) IIV . "1.c ;at" _ : 1' ,,. r ;1. 14: n. I _< <fi >3b3 U1.; .'.ittti, , ..: , e.:...,1.. ':, (7 P C1. 1.0 *s'e i : ' ,).,„1 ✓ *,i! , t t t* t'{ttt(. :1.t 1. f',� ': t.. - 1.}`'i ' ., r._. _..._ t v r' a V ' ' P,!li;eil frr ( }i +Cvt41 .:I <I •r y„ < - 4 1 ✓ i_ V 1.,t i {;)' 9 7 7? S;I } < (iC < t' br' ,U"i t I;\___, .., _.... ., . \,. \ . \ ; r 7 , - - rig se I '� J s 1 11111111M1111111 III 111M1111111 110111E1IIIi i I /_ \, {Note: This drawing is an artistic Designed: 6/28/20121 interpretation of the general Printed: 7/3/2012 appearance of the design. It is I not meant to be an exact rendition. 11 1 I Final Plans.kit 1 All Drawing #: 11' i .. 4/ r , r -,„ ; .-: _ __ ------ -- c■ - .__ .) ._.,) t ., • . — \ • — 1 p-Is ,,.-,;. .. _ _ . (1\ `, .:/ , 1 / : v i / / 4 / (, ..,.. 1 , I , ' v-) i , - /. I I ,,,., ,'• ,. .. : ...` , .,.. : 'J / ,--' ,.? , i , t, „, it '..- i • C) '''•-•). i i - ■. / /V ';':' Y / ; 1 / / / i ,,'' - _ i t .... , - r ' ? L .,' 7-i/ik:/, .2 ly - ' _ .....„...... . , ..," ..,,,..., y 1 ;TA i . , - 1 _ !"/ A , ..,,, / ,.., , . ." • • / --- -••:4. ,.) 1 (i --[.. 1 r\r• , 7 1 , 1 ----- " [ I i i 1 1 . 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 Th_. a inspection process r quir 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 -- - - - - - -- -- permits in sued,_and_ 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 =W ( Office of Investigations • fg ='- a 600 Washington Street Boston, MA 02111 '� www.mass.gov /dia -Workers' Compensation Insurance Affidavit: Builders/ Contractors /Electricians/Plumb.ers Applicant Information / /� Please Print Legibly Name ( Business /Organization/Individual) / D/M 2 L/lrtl G8ae2IL GQ/7T 4 /��"OR— Address: ?O. Sort' City /State / Zip: (, t /- ?� J`� . ,./p/2.._ Phone #: 2 i/3-297-L5,41/ 5 Are you an employer? Check the appropriate box: Type of project (required): / 1. (_v1 I am a employer with ) 4.. fl I am a general contractor and I 6. 0 Ne construction employees (full and/or part time). * have hired the sub- contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. odeling ship and have. no P^iloyees These sub - contractors have. 8. ❑ Demolition working for me in any employees and have workers' Y c aP aci ty. 9. 0 Building addition ss n•anc [No workers comp. insurance repairs required.] 5. Cl We are a corporation and its 10. ❑ Electrical ep irs or additions 3. I- am- a- herneo-wner- -d g -all wort o e s r_aav �t,ezciscd_ it _ 11.0- Plumbing repairs 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 requited. *My applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affrdavit.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. 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: /i 6 ,j25` t ' // /!/T l/GA �/ ?�. Policy # or Self -ins. Lic. #: ' / Expiration Date: - A 2/ 0 10/3 Job Site Address //9 /V4/1/A4 (2d , /`O/L ew6G° City /State/Zip • t)/0,4 (j 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 afi 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 nder the pains and pen = • perjury that the information provided ` uean _comer _ __ re ill!i // � 1.? Date. ;/ viyArAir Phone #: /3 - gig 7 ,_ .5 -74 Official use only. Do not write in this area, to be completed by city or town ojciaL City or Town: Permit/License #_ Issuihity (cr one): I. Board ng Aut of Health or 2i . B cle lding Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector __ _ 6. 6. Other Contact Person: Phone #: I . SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ 11 Name of License Holder : / ° t 2 d/ /q k} ( $ o?o2d'/ License umber ?0, .tor 491 ao_pieit vi //r . 4/o/2 /? - S- c2913 Address Expiration Date ` -297 -S /6 G/ Signature Telephone 9. Registered. Home° Improvemnent:Contradtor ..;., ... ... , .., ., Not Applicable ❑ �� ,7v.Cpry 6eik.iaai, (lL> $ /2 09foo Company Name Registration Number E7,r 21 Addr ss / Expiration Date C b gfeii ht /d �/l• 0 Telephone 1 //3 - 297- gq 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 build' g permit. Signed Affidavit Attached Yes No ❑ The_current_ exemption for "homeowners" was 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 1083.5.1. 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 referencVto 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 amp on •refinance , _` .„ • i s-Gencr-alL-aays:Annotated. • Homeowner Signature . • 'i 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 [C] Siding [p] Other [p] Brief Description of ProPposed _J 'i/ .✓9w Work: 8eMOdei le /14 r A/ 6 *Wvef" 'Veal; vi of w4sh,'4 A 'tye.. i.v ✓ r /&pots- 4 w -L Alteration of existing bedroom Yes No Adding new bedroom Yes No / Movie iaih er Attached Narrative Renovating unfinished basement Yes ../ No Plans Attached Roll - Sheet I;a_ if.. Nevu house'',and or :addition.to'exitinq'houshiq; complete the fo[Iouving: 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 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 C ®MPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERM 1, • ' , , as Owner of the subject pro hereby a' • rize / i i ' , 4 " to . ' in my behalf, in -, m- ers r- - a to work aut orized by this building iermit application. WM. dad 1. _... ' aa.O / _ Signature of Own -a(orti L / vin A o, 6 I / 4e/7 (fin.42A0/ , as Owner /Authorized Agent hereby declare that the statements and information on t (fin application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. - 7O41 "Dvh4t Print Name ' ~Al- , r/ liti Signatu of Owner/Agent D 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 Ct Lot Size Frontage Setbacks Front Side L. ,_._ _. R. _,_ ,_ L:,_ Rear ... Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved m, parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 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 # F B. Does the site contain a brook, body of water or wetlands? NO 0 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 0 IF YES, describe -size, type and location: j D: ie t�iere any proposed aii "n'ges to or a itions o signs inten�ed-for the property ? YES 0 NO 0 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 0 IF YES, then a Northampton Storm Water Management Permit from the DPW is required. � - � P = -� ,� r,mk e s e on - i 0 r City of Northampton stafus p f Perm U Building Department Cii tifi w a i RO s it s 212 Main Street SewSefrt3Auariaf r[y ; � � A, 6 21112 1 Room 100 1/lla en # tI Avaria ttt (' S t q -- Northampton, MA 01060 T a sh , pEiT. of suiLa!au iNsPecrroirs ph ne 413- 587 -1240 Fax 413- 587 -1272 Pi�pf/ ° to � an � 0 NORTHAMPTON, MA 01060 ' e - Other Speef �` p 20 APPLICATION 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: .e /h2. We0AA1 / ; .A �� Map Lot Unit , CAOR'vC „`4. O/dbo Zone Overlay District Elm St? District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: r �- !_ard ,-n --- - -- -- _ _ b/2 .e. xn - ae eoize /14, ev000 Na ex Print) ` Current Mailing Address: Si nature T elephone G i ii 3 — 2-3 —,30 .2, 9 2. orized Ag 7 D O,C aW ? a, / 014 a e‘.5 iriCeb 4. D /v/Z Name (Print) Current Mailing Address: � _i i — - , . til- — 2", 7 --- (57 6 Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION-COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 3y , , . 2. Electrical (b) Estimated Total Cost of b o Soon Construction from (6) 3. Plumbing acs Buildi Permit Fee ZZOa ,3 4. Mechanical (HVAC) 5. Fire Protection �/� 6. Total 7T {1 +2+3 +4 +5) 3/ p f3S, °c) Check Number r j / / This Section. For Official Use Only Building Permit Number. Issued: i '�_ - / Si nature: �,, � ,. A 9 Building-Commissioner/Inspector of Buildings Date 112 NORTH MAIN ST BP- 2013 -0105 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C - 266 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- 2013 -0105 Project # JS- 2013- 000167 Est. Cost: $39538.00 Fee: $237.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: THOMAS DOLAN 039281 Lot Size(sq. ft.): 5052.96 Owner: GIARDINA ANTHONY & EILEEN Zoning: URB(100)/ Applicant: THOMAS DOLAN AT: 112 NORTH MAIN ST Applicant Address: Phone: Insurance: P 0 BOX 297 (413) 585 -0612 () Workers Compensation CHESTERFIELDMA01012 ISSUED ON: 7/27/2012 0:00:00 TO PERFORM THE FOLLOWING WORK: REMODEL KITCHEN,CABINETS,NEW WINDOW,RENO BATH 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 7/27/2012 0:00:00 $237.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner