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17C-017 (2) D escrlptor/Area ,: 2Fr/B mood Deck 1152 sgfk 1 B:CFP X56 132 sgfk C: C FP 0 sgfk DA Fr 60 sgfk 18 2Fr/B 18 E:FBAY 2 21 sgfk F:Wood Deck 24 256 sgfk 5 -D 55 _�C 5 i� i 28 3 18 V 3 24 2.? B 2 280.5 i 74.25 t C 016 74.25 1 f 116 292.12 1 2 74.25 17C-Oi7 74.2 305.11 4 i 82.5 17 C-O 18 82.E i HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 7800,m 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 occupancv 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 I, understand the above. (Home own r/resid is signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date 41/ZJ 0 Address of work location Atmy— � The Cotnmoi�weaith oflLlassachusetts Detnarnment of IndfustriaJ_lccidenLs n`^ o;lnves�ir~<cns _ 000 Ffwshzngton Street Boston, 31=I 02111 www'.mass.-o;ldia tivorkers' Compensation Insurance Affidavit: Builders/'Contract ors,/Electricians,`P1r.Ilrbers Applicant Information Please Print Lesibly N=?— (Business'Organi:ariorv'Individual): _ Address: City;%State,'Zip: Phone Are you an employer? Check the appropriate boo: Type of project(required): I 1.❑ I am a emplo •e. with 4. ❑ I am a general contractor and I y '� 6. ❑New construct-ion emplovees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodelim ship and have no employees These sub-contractors have S. Demolition emplovees and have workers' working for me in any capacity. 9. ❑Building addition [-To workers' comp. insurance comp. insurance.: required.] 5. ❑ W e are a corporation and its 10.❑Electrical repairs or additions I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. o workers' comp. right of exemption per vIGL ., fff y L ❑Roof repairs insurance required.] ' c. 152, §1(=1), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that check;box#1 must also ill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new amdavit indicating such. ,Contractors that check this box must attached an additional sheet showing the panic of the sub-contactors 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 Comr---,nanv Name — Policy-` or Seif--ins. Lic. Expiration Date: Job Size Address: City/State/Zip: Attach a copy of the workers' compensation polio declaration pale(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of vIGL c. 152 can lead to the imposition of criminal penalties of a tine 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 fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investizariors of the DLL:for insurance coverage verification. I do hereby certify tinder the pain and pe aof perjury that the information provided above is trace and correct. �a Date: Phone 0,Jicial use only Do not write in this area, to be completed by city or town of ciaL Citv or Town: Permit/License f i Issuing Authority (circle one): 1.Beard of Health 2.Building Department 3. City/Town Cie:k 41.Electrical Inspector 5. Plu_. bin.-Inspector 6. Other Confiner Person: P.one SECTION 3 -CONSTRUCTION SERVICES ,-I Licensed Construction. SuoerAsor: Not Applicable ❑ Name of License Hclder License Number "dcress Expiration Date Signature Telephone r.Reezistered Home,tmaroverite6tt OoafractQrw± w y Not Applicable ❑ .omoany Name Registration Number .ddress Expiration Date Telephone ECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.452,§25C(6.)) 'orkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result the denial of the issuance of the building permit. gned Affidavit Attached Yes....... ❑ No...... ❑ 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. SLYth 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 buildinZ 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 15' (Liability of Employers to Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,you may be Iiable 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 /ortnampton Ordinances, State and Local Zoning Laws and Statte�of Massachusetts General Laws Annotated. Homeowner Signature / I - SECTION 5-DESCRIP70N OF PROPOSED WORK(check all ar)oiicabie) t INew House Cj Addition Replacement Windows I Alteration(s) CC I Roofing Or Doors 0 Accessory Bldg. ❑ Demolition u New Signs n] Decks [LJ Siding[=,i Other=1 Brief Desorption of Froposed C Work: �.J Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans At ached Roll -Sheet 6a. if New h6u- 2R( a�iaadniOnl fQ exiSiFTIQ h66sfha.comd4te the=fo[ av+rina.: 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 stores? 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. floodpiain 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 €0 SE COMPLETED_WHEN T. OWNERS AGE T OR GONTRAC€OR APP L1E5 FOR BCfILDtNC PER N11T as Owner of the subject property hereby authorize to act on my behalf, in ail matters relative to work authorized by this building permit application. Signature of Owner Date 1 as Owner/Authcrzed Agent hereby declare that the statements and informat:on on the forgoing application are true and accurate, to the best cf my kncwiedgE and belief. Signed under the pairs and penalties of perjury. f Fnnt i j i ^ ~ Section 4. ZONING ALL Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information This coittttin to be flill,�in by Building Department Lot Size Fro�ntaze Setbacks Front Re Building Height Bidg, Square Footage % Open Space Footage (Lot area minu5 bldg&paved #of Parkina Spaces A. Has a Special Permit/Variance/Finding ever been issued for/on the site? -\ /~� � u�� NO \~� DONTKNO�' \_� YES N�� ` IF YES, date issued:'Do IF YES: Was the permit recorded at the Registry ufDeeds? �� NO �� DONTKNOYY YES � IF YES: enter Book / ( Page and/or Document#| � B. Does the site contain a brook, body of water orwetlands? NO DONTKNOYY 0 YES y=\ IF YES, has permit been or need to be obtained from the Conservation Commission? Needs tobeobtaned y—\ Obtained �-� Date' v_� ' \_/ ' C. Do any signsexistontheproperty7 YES 0 NO IF YES, describe size' type and location: ^ ' D. Are there any proposed changes toor additions cf signs intended for the property? YES 0 NO IF YES, describe size, type and location: E Will the construction activity disturb(clearing,grading, excavation, or filling)over acre oris it part ofaconmon plan that will disturb ever I acre? YES � ] NO K�Y ~� ~u IF YES, then a NortFamptohS5do�Wffe_r Min����ft-Pennit from the DPW isrequired. Department use only City or NOrt,2mpton status of Permit.- _-- "_�L1r Department Curls Gut/Driveway Permit r— �(� _. 42 Main Street SewerlSepticavaiTabiIity r 40M 100 WateiJWell Availability �.. rtha ,'on, MA 01060 Two Sets of Structural'Plans JUN pt�o�e 581-124.0 Fax 413-587-1272 PlotfSitePlans . _ Other Specify OjAa APPLJ�i"d"+O�VjN� UCT R,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -S1TE_INrORNIATION This section to be completed by office 1.1 ProDerty Address, //e ("✓�J j, /0 /�'lapl Map Lot Unit 00 dd Zone Overlay District Elm St District CS District SECTION 2-PROPERTY OWNERS HIPIAUTHORIZED AGENT 2.1 Owner of Record: MA9V Name(Print,,,)///►►►!!! _ Current Mailing Addre WWITelephone (J 7 Signature 2.2 Authorized Agent: Name Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item I Estimated Cost(Dollars)to be Official..Use Only completed by vemit wolicant 1. Building �!,`�• �` (a}But7ding Permit Fee Vo 2. Electrical VV j_(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) Check'Number- This Section For Official Use Only Date Building Permit Number. Issued: Signature: -- -- --- ------ Building,CommissianeT/lnspecto�of Ewidings "' " Gate File#BP-2008-1126 APPLICANT/CONTACT PERSON JENKINS MARY ANN ADDRESS/PHONE FLORENCE PROPERTY LOCATION 106 NORTH MAPLE ST MAP 17C PARCEL 017 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid T_ypeof Construction:_ERECT 8 X 8 SHED 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 FQrLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 0//1724:�1043? 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. e + :; BP-2008-1126 no 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) Category_ BUILDING PERMIT Permit# BP-2008-1126 Project# JS-2008-001656 Est. Cost: $25.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 22302.72 Owner: JENKINS MARY ANN Zoning:URB Applicant: JENKINS MARY ANN AT. 106 NORTH MAPLE ST Applicant Address: Phone: Insurance: FLORENCEMA01062 ISSUED ON.612012008 0:00:00 TO PERFORM THE FOLLOWING WORK.-ERECT 8 X 8 SHED 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 6/20/2008 0:00:00 $25.003957 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo