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25C-151 (2) Lt=npcor, MA 01060 I- A A EW01V EDGE, IENT -L- C. L k-,' ER EX I 7-1-he Stan o--,c'M-assachT:se-r,-s allows 'U-I-- horn--owner the ri-crliL under 780CMR 108.3-4 to " act aE Construcrior r, Sur,� 'he -IeEzes "Homeo wner a -Son(s) who owns a parcel on which he/she resides or intends to be, a one or twofandly attached or detached structures accesS iy to s, ccures. uch, us.e and/or fa---,,2 S--L person who con.-,tracts more than one home in a n-vo-ve-ar period shall not be considered a home o7,mer-- T-he bur ding--departm ent., for t-lae City offNor-,h,-=pton want's any person(s) who seek to constr to n7=7-i- U S-1 the home OV-,Me,-exemption, to act as their Own that by doing so vou become responsible for compliance with state building codes and regulations- The inspec-Lion process reeqluires that the building departm, ent be called to i=. per work at various stagges, which include foundation/footings Cbefore backFIAM. sonotube holes (before oour). a rough building inspection:(before work is car.ceidedI i-Rsulati" insuectian (if reguhred) The building depar=ent re—quires these inspections before the work is concealed, failure to secure these. inspections can result in failure to obtain-a certiBcate of occuo:ancv umtil the-w-ar-k-can-be insuected- L-7the homeowner hires other trades to per dorm-work(I.ectrical, plumbing&gas) the homeowner will be responsible to mare sure thaft the tracfes hired secure their proper- per its in conj,--ction to the building pe=t issued, and that they get their required inspections.Failure o.-Fthe individual trades to secure the pe.-Mits; and inspections as requ.;redf can DELAY tie prc)j----, until such time as the proper permits and inspections are made =,derstand the above_ (Home_owner/resident's signature requesting exemption) I will call to schedule all required building inspect ions necessary for the building pe.-rrut Issued to me. Date Address_ locanor. Le ct,tP�tettl of d, �tts�,-1 �ccat 1-1 Office of In��estigations 600 tlashiniton Street Bostfln, 31A 02111 n w.naass.,1% w dia Workers' Compensation Insurance Affidavit: Builders/Con tractors/Electricians/Plumbers A nplicant Information Please Pririt Leaiulr Name (Business:OrLanization,-Individual): City/State/Zip: I'tai 4W 70 iJ �ul,� 01�U Phone #: Are you an employer? Check the appropriate box: Type of project(required).- 1. �I any a em foyer-with ❑ I am a general contractor and I p 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors ?.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp. insurance comp. insurance., required.] 5. ❑ We are a corporation and its 10.F71 Electrical repairs or additions ❑ I am a homeowner doing all work officers have exercised their 1 I.E] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.7 Roof repairs insurance re uired. c. 152. §1(4),, and we have no q ] employees. [TNo workers' 1 ❑ Other comp. insurance required.] 'Any applicant that checks box 7,1 must also fill out the section below showing their workers'compensation policy iliformation. Ho meowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. -CUnllaCLors that checi<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 thepolicy and job site information. Insurance Company Name: - Policv t#or Seif--ins. Lie. n: WC� �� �/5 — �� J`721 7 Expiration Date: 0,�; /57- - ` t�Fc..6p,�10 .�" Ci /State/Zi 'I. o �`l�9w,,1TEJ lG1., Job Site Address: /?-'//, n' p' � �� Attach a copy of the workers' compensation policy declaration page (showing the policv 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 S 1, 00.00 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 for-arded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerrifi-under the patrrs rrntl pens ties-o pe>Juin�that-the information provided above is tare and correct Signature: Phone T 7 __ l_OficiaLuse..orall �u uut�vritenlhis_ate_a4 to be completed _city or town offcicrl — --- ----- -City or Town: — -- -- Permit/License m Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. Civ,/A own Clerk 4.Electrical Inspector Plumbing Inspector I o. Oilier �I Contact Person: Phone u SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction ySupervisor: Not Applicable ❑ Name of License Holder: License Number 1 2 A5 Address Y Expiration Date Signature Telephone �� (3/0 9. Registered Home Improvement Contractor: Not Applicable ❑ Company Name Registration Number 7 i f5�j 4, , w 7f i�0�l Address Expiration Date /,&c X7,4 f� 'er' 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 buildipg permit.- Signed Affidavit Attached Yes....... IV No...... ❑ 11. - Home Owner Exemption 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-vear period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official, on a form acceptable to the Building Official.that be/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 W" dows Alteration(s) Roofing ED Or Doors [ta i Accessory ld ❑ Demolition g [ ] [M Siding [2e/ Other[C]] ry g. New Signs C7 Decks Brief Description of imposed Work: N i A l 1 t'i PJ, !(i?. �4/E N, t:Je<a -�' / Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a.-If New house and or addition to existing housing,'complete the following 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 COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. !/l�✓� �' �� as Owner of the subject property hereby authorize _ � � r'3 g,4 1 to act on my behalf, in akmatters relativ to work authori ed by this building permit application. Signature of Owner Date 's—j o- olf 1,_ J�E7'0'' b() '0�, as QY"r/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 Signature of QWW/Agent Date 3 -75`7-0 ' I 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 L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage (Lot area minus bldg&paved parking) #of Parkins;Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW Q YES Q IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO Q 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 0 DONT KNOW 0 YES Q IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Q , Date Issued: C. Do any signs exist on the property? YES 0 NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended 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 O NO Q IF YES, then a Northampton Storm Wat&Management Permit from the DPW is required. Department use only City of Northampton Status of Permit: !Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability ` Room 100 Water/Well Availability 1 v Northampton, MA 01060 Two Sets of Structural Plans v phone 41.'-587\'1240 Fax 413-587-1272 P16VSite Plans Other Specify APPLIGAt'6Ii'TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION,.---SITE INFORMATION 1.1 Property Address: This section to be completed by office )2 17 tJ Map Lot Unit ✓� ''0' � Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) 7 � r Current M4Wr)g Addre k XA Q>� Telephone Signature -5 S3001 2.2 Authorized Agent: Name(Print) Current Mailing AddrE s: It Siglinature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building G (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from- 6 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total= (1 +2+3+4+5) v v Check Number This Section For Official Use Only Building ermit Number: Date Issued: Signature: Building Commissionei/Inspector ofBuil mgs Date BP-2008-0766 GIs#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cates,ory: BUILDING PERMIT Permit# BP-2008-0766 Project# JS-2008-001184 Est. Cost: $24850.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: ('oast. Class: Contractor: License: Use Group: B & R Siding 100465 Lot Size(sq. ft.): 601128 Owner: BATTEY MARK A&JOY A Zoning: URB Applicant: B & R Siding AT. 17 ORCHARD ST Applicant Address: Phone: Insurance: 781 Bridge Rd (41-1) 586-4167 Workers Compellsgtloll NORTHAMPTONMA01060 ISSUED ON:311112008 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS & SIDING 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 Occuipancy Si nature: FeeType: Date Paid: Amount: Building 3/11/2008 0:00:00 $25.0021176 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo