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17C-120
c tyq,KpT f ,,� UEPF_RT2v*_ NT OF EUILt7rhG ItiSPEr`TIONS INSPECTOR 2112 Main Street 0 Municipal Euilding "��,/ Nor bxnpton, MA 01060 �,��;�-�� -EXERTION ACK' OIVVLEDrFMFNT 3-1 The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as risilher construction sup.... or. 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 come in a two-year period shall not be considered a I home owner." The building-department for the City of Northampton wants any per sons)who seek to use the hone owner exemption, to act as their own construction super visC, 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 backfll). sonotube holes (before pour) a rough building insaection (before work is can-ce led). insulation inspection (if required) and-a-rhial-buildina.insnecti.o.n. 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 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 T 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_ Dale • Address of work Iocation The Commonwealth of Y_rassachicserts �-- Department of In dustrial accidents Ori"zce oflnvesrigarions ' � SDD Washin910 n Street Boston,31,4 02111 www.mass gov/dia Workers"Compensation Insurance A�fidaNit: Builders/Contractors/Elee-tricians/Plumbers ADolicant Information Please Print Lesibly 1V ame (Business/Organization/Individual):_ mad-.-ss: City/State/Zip: Phone.: L4 1-j S Are you an employer?Check the appropriate box: Type of project(required): 1_❑ I am a employer with 4. ❑ I am a general contractor and I have hired the sub-contractors 6 []'New construction /employees (full and/or part-time)-* _ ! -, f�l ,_.� proprietor on the attached she . r1 Remodeling i I _ ��.a sage rroprietor or pa.-�er- �: ----� ship and have no PnapIo;ees These sub-contractors have g- ❑Demolition working for me in any capacity. employees and have workers' 9. ❑BuiIdins addition I i nv wo Viers'cow. s,uance coma.mSurance.+` L v r 10_❑Electrical repairs or additions required-] f_ ❑ F e are a corporation and its :.❑ I am a homeowner doing all work oficers have exercised their 11.❑ lumbing repairs or additions myself- [No workers'comp. rift of exemption per MGL 12.�oof repairs insurance required.]9 c. 152, §1(4), and we have no employees. [No workers' Ili.❑Other Comb.insurance required.] ------"xnv app ican sire✓ ooz�. nnist aso out the soon oaow snowing - ea woricss'comp®sation policy miormaIIOa ------ _ 'Homeowne s who subttzrt t3tis affidavit indicating they are doing an work gad then hire outside conII�cozs mustsubffit a new ainaavit indicat nr such. *Contractors that check this box must.auached as additional shit showias the name of the sub-coattactots and safe weedier or not those entities nave e:npioyees. if the sib-cont:actors.have empioy=,t'iey must provide their workers'comp.policy numb lam 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.r: Expiration Date: Job Sire Address: City/State!Z# 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. I52 can lead to the imposition of criminal penalties of a fine up to$1.500.00 and/or one-yeas imprisonment, as well as civil penalties in the fol-m of a STOP WORK ORDER and a one 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 Investigations of the DLA for insa=ce coverage verification. I do hereby cerz<fy under the pa' andpenaL es ofperjury than the information provided above is true and correct Date: Phone#: 3 uUI LM i use miiy. Uo not write to this area, to be completed by city or town officiaL City or Town: - -- -- --- ---- _ —P-er-mit/License Issuing Authority(circle one): I'Board of Health 2.Building Department City/Town CIerk 4.Electrical Inspector S.PIumbing Inspector b. Other Contact Person: Phone.- 1 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: R�T l� -A 0 S (__17 1 ti,,1r�f —( License Number Address Expiration Date Signa ure Telephone 9.Registered Home Improvement Contractor: Not Applicable ❑ C pane Name Registration Number Address ( Expiration Date Z,.vNN r� Q a r-� 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...... ❑ 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 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 Or Doors F7 Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding [❑] Other[❑] Brief Deifri tion of Proposed C,1 Work: +C1�SZ"yw ors �T'(S Q� Y�4% ppT Alteration of existing bedroom Yes No Adding new bedroom Yes No 1 1 s" 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 as Owner of the subject property hereby authorize to act,oi my behalf, in all matters relative to work authorized by this building permit application. CX11 �4r� 1 Signature of Owner Da 1, as Owner/Authorized Agent heretf 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 OwnerlAgent Date 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 oarkin ) #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 0 IF YES, date issued:° IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES Q IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 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 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 disb_irh(Haaring, 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. A � Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Server/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify 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 -�� She�';� , Lc�,, © Map Lot Unit ` Zone Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name t Current Mailing Address: Telephone hgn-ature �' 1 2.2 Authorized Agent: , Name(Print) Current Mailing Address: l_ V -\J� (� /`moo . C 7 `'� Signs ure Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (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+6� �� Check Number This Section For Official Use Only Date Building Permit Number: Issued: Signature: _. - - ---- —ecto- -----o—ne-r/Insp --o w mgs Date Budding Commiss BP-2008-0501 GIs#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON k..' 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-2008-0501 Project# JS-2008-000753 Est. Cost: $6480.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin BOB THIBODO ROOFING & SIDING 152172 Lot Size(sq. ft.): 381 15.00 Owner: WESTORT PAUL A&NANCY A Zoning: URB Applicant: BOB THIBODO ROOFING & SIDING AT. 34 SHEFFIELD LANE Applicant Address: Phone: Insurance: P O BOX 201 (413) 527-7663 () NORTHAMPTONMA01061 ISSUED ON.1111312007 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE REAR 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 11/13/2007 0:00:00 $25.003194 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo