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32A-058 (9) r $ Lx#-P of Narf4aillvton ^J I�� I � � �A54ACh1(Sttf9 `I " DEPARTMENT OF BUILDD7G INSPECTIONS /= INSPECTOR 212 Main Street • Municipal Building Nortlimnpton, MA 01060 t• HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sup-.,P sor. T he stale 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-yeas period shall not be considered a home owner." The building department for the City of Northampton wants.any 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 backfiIl), 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 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 owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia -Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyiblv Name (Business/Organization/Individual): Address: rW OL ,rv-ti o�. City/State/Zip: 04u . 0 15'f U Phone.#: VP Are you an employer? Check the appropriate box: Type of project(required): 1.0 I am a employer with_� 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 0 Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working or mein an capacity. employees and have workers' g y p �' $ 9. ❑Building addition [No workers' comp.insurance comp.insurance. 10. Electrical repairs or additions required.] 5. ❑ We are a corporation and its ❑ eP 3.0 1 am a homeowner doing all work officers have exercised their 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' 131J Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit 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: uu r% Policy#or Self-ins. Lic.#: ��b CS11SyQ`� Expiration Date: Job Site Address: Sb U.t't'i S �in t oZ `l City/State/Zip: O (p(Q 0 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$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$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 DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town offzciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction u erv'sor: Not Applicable ❑ Name of License Holder: r- cJZ ck C-)�11 cO _` License Number Addr ss Expiration Date Signa a U Telephone 9._Reaistered'Horie frirciraverirertt.Cantractor . = Not Applicable plicable ❑ Company Name Registration Number Address t J . Expiration Date A `t o�U �t'G�✓�/ y �c�, you Telephone_-((3'�Yp-3`'�3� SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT I(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...... ❑ 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-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"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 O Accessory Bldg. ❑ Demolition ❑ New Signs (OJ Decks U Siding[O] Other Brief Description of Proposed Work: r/vl0 C� �CJ Alteration of existing bedroom Yes�_No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa If I ew�iause grid oraciclit orr to ezist� ci harisirict ycari 616 fh- faICouvii c 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, Lt) - i C C1 as Owner of the subject property hereby authorize 1-1 , to act on my behalf,in a I ma ers elative to work authorized by this building permit application. e- Siggerure of Owne Date as Owner/Authorized Agent hereby declare tbat 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. +L-.e-.x n-1 5 , Print Na C) Signature o ner/Agent Date , ~ ^ . ` Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This coltimn to be filled in by Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Permit/Varianoe/Fndi ever been issued for/on the site? �� NO �� DON7KNOVV «��_ YES «��� � IF YES, dataissuem IF YES: Was the permit recorded at the Registry of Deeds? NO K } DON7KNOVV YES ~� IF YES: enter Book Page and/or Document | � �� �� �� B. Does the site contain ubrook, body of water orwetlands? NO ��� DON7KNOVV �_� YES �_� IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs tobeobtained «���~� Obtained /�\ Date�_/ . � C. Do any signs exist on the prupert ��y? YES v�� 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 IF YES, describe size, type and location: | / E. Will the construction activity disturb(clearing,gradiexcavation,ur filling)over 1 acre oris it part nfo common plan that will disturb over 1acre? YEG ���) NO �){} IF YES,then a Northampton Storm Water Management,Permit from the DPW is required. Department use only City of Northampton Status of Parmit _ Building Department CurtCutlDnvewayrF'erm '` ff 212 Main Street l6b* t� _ Room 100 V a ertV ell'Vailabikify . Northampton, MA 01060 TwaSets of`ScfurafPlans ` `{ phone 413-587=1240 Fax 413-587-1272 PiotlSite Plans Othee Spectfy APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be contCeted h}roffice 1.1 Property Address: Map ! Lot tln�t -50 �A t C1.1 �Jt v l� a` Zone': "Overlay District Elm'SY Disfict CB E)fatFict SECTION.2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Na erp (Print)•r•�--''' Current Maims lirw A/ddress:Q`� I Telephone SignatIrre 2.2 Authorized Agent: ��� J p Name Print) Current Mailing Address: Ll i'3 --q-[4-71(31 Signa-tuft Telephone SECTION 3-ESTIMATED'CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 0 o b • ao (a)Building Permit Fee b 2. Electrical (b}Estimated Total Cost of " 15700. 5C "Construction from 6 3. Plumbing -o � Building Permit fee 00 . 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) a3 U o p • v O Check Number This Section For-Official Use Only Date Building Permit Number. Issued: Signature: Building Comm issionedlnspector of Buildings Date File#BP-2007-0895 • APPLICANT/CONTACT PERSON HENRY J SOUZA ADDRESS/PHONE 24 OLD FERRY RD HOLYOKE (413)949-3431 PROPERTY LOCATION 50 UNION ST#24 MAP 32A PARCEL 058 024 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: REPLACE KITCHEN CABINETS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 087984 3 sets of Plans/Plot Plan THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN 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 Commis Z 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. " .w. BP-2007-0895 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -024 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category BUILDING PERMIT Permit# BP-2007-0895 Project# JS-2007-001459 Est. Cost: $23000.00 Fee: $100.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin HENRY J SOUZA 087984 Lot Size(sq. ft.): Owner: RIPPEL JENNIFER L& Zoning:URC Applicant: HENRY J SOUZA AT. 50 UNION ST#24 Applicant Address: Phone: Insurance: 24 OLD FERRY RD (413) 949-3431 HOLYOKEMA01040 ISSUED ON:41412007 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE KITCHEN CABINETS 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 4/4/2007 0:00:00 $100.001313 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo