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37-113 i ct1AMP, O aveme �_ ,/ Oitf r of NorfIIumpfon )z =- 1 ii �� � r '� fg assacllusetts , ---. _:17#. - DEPARTMENT OF BUILDING INSPECTION , _ ' :3_ f /, INSPECTOR 212 Main Street • Municipal Building ',- > Northampton, MA 01060 • e HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his /her construction sups: ,'i sor. The state defines "Homeow-ier" 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 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 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 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, nderstand the above. (Home owner /resident's signature requesting exemption) I will call to schedule all required building inspections necessary r the building permit issued to me. i Date Address of work location 1 -cit./Q P2. • 0 .= 011.i tiT oi Northampton =-_-. - .4 • • `8' 44 ."" DEP ARTMENT OP DiJILDING INSPECTIONS : • MO = - 212 Main Street Municipal Building Northampton, Macs. 01060 W 0 RKER S COMTENSAIIO N INSURANCE Arai) A \IT ___624:07 vt- 6 C _ --- (I i v,'ith a prin cipal plac,e of business/residenct-2 1397 _ ‘1 PD0 clo hereby cer unc1 rile pains and penaltict; ot ( ) I am an employer providing the follov;i nc:. v:orker compensation covelT.:::.e for my employees working on this job: - (Las Company) Number) Date) ) 1 any a sole prourietor, general C-OLlsaCT.01 horneowne: (circle one) and have hired the contractors listed beioviv,:ho have, the. foilo viorker's compensation 7, (Name of Contractor) (Insuranc::, Nuitnbor) Date) Marne of Contraci.or) CompanviPol.ic7 Number; (1.1xuiranon Date) (Name of Contractor) CoMpauyielpolloy Nturber) ,:1 Date) ("Name of C'ontmctor) (Insuranct Conr;ar,y(Pol.ic Numb-2r) (Tixprntior, Dae) if T.:I:. • - It 11 11 i sole pro or aid have no ohe for me. (.‘ ) I arn a hone ovine: 1)er:o:Thing all ft' NOTE: c:npkry ti) C1,.:C2.C CZ :rpair not floc th:n darco units in v„ cx:‹ cz_npl oyc.3 undcr t.h (G ! (5)), a hotncosmcr for a Lc = c x: Itsm.laztuz of an eznployo-c under tho Workcea Ojc, Ac 1 undc--aDuad Lilal. co-py of thi 1r.yl.o forwarchri to t.l.: of Inclautri ofnc-c of for Lb' �v- i vcrifi=tioct and that fz to : 25A of MCI., 152 can Icl_•d to the irnpositicki of cr....-niaLl pcnallics conniving of a fin, o to ;1.500.00 of up to on:. y civil pcnaltics in I< fonn Of !t Ste-, fir of:510.0.0a a clay irjn.i m-_ For 1.114 only Pcrrnit Ntullbc-r _____ 1 Ae l dAT I gm\ tut/ SECTON 8 ;:CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : 64/e `y ,Q C4 1 3 E // t�0 �/a� c 5 73 7628 License Numb a /�1 I / ��'' � ,� . v� F� o �F �vc nl ✓ a 7 /goo Address Expiration Date 7 ao 9— Signature Telephone . 1... 4 „€.6t2-- Red . a .orne fl a semen .�n ra'cto 5 ere �_�``���- �.�-°. ,� ��. =�' �,�, ,..rv:� Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTI0N°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 ❑ The current exemption for "homeowners" was extended to include Owner - occupied DwellinEs 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) Lnd 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 compliaice with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachw etts General Laws Annotated. Homeowner Signature .aSww' nit ""' ''" SEC�T,ION�O�SCR r.e Ica •.e New House Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ] Brief Description of Proposed Work: /3c# / £.4 C' •4-7 E' Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0 - Sheet; Mr"- ,e =.' e door ndd:ition `to ezisfin;r- housmgsWcomp'1:e a the foloWing: a. Use of building : One Family x Two Family Other b. Number of rooms in each family unit: Number of Bathrooms .3 c. Is there a garage attached? )tS d. Proposed Square footage of new construction. a/,a a Dimensions 3.3 x S3 3 e. Number of stories? / f. Method of heating? (9i ,967 1 � rQ Fireplaces dr Woodstoves / Number of each / g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? h. Type of construction Pi r►? e 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 7 c k. Will building conform to the Building and Zoning regulations? '\ Yes No . I. Septic Tank City Sewer fK Private well City water Supply )( SECT30f�t7a0Y1jNERUTHORIZATION "TO BEiCOMPLETED :WHEN OWNEF{SsA(aENOFCONTf3ACTOR APPLIES FO BUILDING PERMIT , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date , , as Owner /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 Owner /Agent Date 1 . Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by Euilding Department SC F'7" / Lot Size ! 6 Frontage a ' Setbacks Front Side L: /5 R: /3 L: /s 1 R: 14 Rear Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg & paved parking) # of Parking Spaces Fill: (volume & Location) A. Has a Special Permit/Variance /Finding ever been issued for /on the site? NO DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page a /or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW YES IF YES, has a permit been or need to be obtained from the Conse :bon Commission? Needs to be obtained Obtained , Date Issued: C. Do any signs exist on the property? YES NO IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property ?YES No IF YES, describe size, type and location: City of Northampton s. Building D epartment r if 3 t #' 9 ., 212 Main Street _ �,t. : Room 100 : � E 4 O � err �5. Northam ton MA 01060 phone 413 - 587 -1 Fax 413 - 587 -1272 � t ' .. a APPLI TO CO NSTRUCT, ALTER, REPAIR, RENOV ._Co OC S A2004 ��• h O ' • FAMILYDW . 1 l ` r\ � , j �;, J UL 2 0 L SE CTIO N 1- SITE INFORMATION � 1 co P eted office 1. 1 Property Address: " ,= o ai , , t /fro lcE f o 'N1 � Del ✓� x a>� Ila ur 4 O T a3 zo O vistnctz MAE St. D�s#nc " : = CS Distr crt SECTION :'2 - PROPERTY OWNERSHIP /AUTHORIZE AGENT edi-de. 2.1 Own of Record: Name nt Current ing s : �� A .� � �' � Telephone p signs a / Cti / 3Addres� 3 O � O — 7 0 0- 2.2 Authorized Agent: (54K �. C4.- y "i F. i 02 y 4d s �.�� 4 Name (Prin� Current Mailing Address / Signatur �� Telephone SECTION; 3 - ESTI MATED CON STRUCTION COSTS Item Estimated Co (Dollars) to be Offi Use Onty completed by permit applicant 1. Building �� 7 f (a) Building Permit Fee v-p m (6) d To 2. Electrical (b) Estimatetal Cost o / 0 :07 , Constru fro 3. Plumbing Building Perm Fe e a 2 d o 4. Mechanical (HVAC) 5. Fire Protection w� � • 6. Total = (1 + 2 + 3 + 4 + 5) a �p J . gy p Check Num ber thi Section For Offi cial Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Insp of Buildings Date • File # BP- 2004 -1085 APPLICANT /CONTACT PERSON GARY R CAMPBELL ADDRESS/PHONE 24 BAYBERRY LANE FLORENCE (413) 586 -9002 PROPERTY LOCATION 16 ICE POND DRIVE - LOT# 23 MAP 37 PARCEL 113 001 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Ill Fee Paid /M' (a Tvpeof Construction: CONSTRUCT 2 STORY SFH/ATT GARAGE/DECK/PORCH New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 073728 3 sets of Plans / Plot Plan THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 C 'ssion 6 --.*Ilf••''t5 f 4 7 C 12:5"----"------- 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. o¢ innMp 2o .-\ ,, :t Q a r of Northampton • , . iiry g assacttusctts — _ � DEPARTMENT OF BUILDING INSPECTIONS ` , __ - INSPECTOR 212 Main Street ® Municipal.Building Northampton, MA 01060 UP ' , CERTIFICATE of OCCUPANCY and USE This is to certify that permission is hereby granted under 780 CMR, sixth edition of the Massachusetts State Building Code, allokving the occupancy or use of the premises or structure or part thereof located at 16 Ice Pond Drive - Lot #23 as shown on the Assessors Page# 37 , Lot 113 , Zone SR in the City of Northampton, as herein specified: CONSTRUCTION TYPE(780CMR 6) 5B USE GROUP CLASSIFICATION (780 CMR 3 - R4 OCCUPANT LOAD PER FLOOR (780 CMR Table 1008.1.2 40 PSF .30 PSF LIVE LOAD PER FLOOR (780 CMR Table. 1606.1) Under the following limitations, special stipulations, and /or conditions of the permits: " Issued this 10th day of February , , , 20°5 Certificate of Occupancy and Use # BP- 2004' -1085 Authorized Dep. ent Personnel Electrical t _ I- - - -. --� p( Elevator t Fire i Plumbing t� Building //A ,� L Gas 1 to}.:) Building Commissioner -- This certificate shall be posted by the owner, in a permanent manner and in a visible location, on all floors designated as use group H, S, M, F, or B, and in every room where practicable of use group A, I, R -1, or R -2 per requirement of 780 CMR section 120.5 Posting Structures. •�. ( e - ,17 ---- Yue9dv hrtgingirs' -90vv:-., ho 07-° 00- / ©/,.�r� -,, ->r- 7 .32 / / a-0 d/ _ 11,, -.9 ,_3,./9,7,- , P '?' /' .5 s-1 " 1,/ //,/" 6/2- ---- /at? (7 A /vim c-,,, c, 9 rye,, )., .7/e/ /o _i9 `42,0 ��, 4 ./1 *(7 d, z i1 -5'6/81/4 ,� /� _ ? / / 014i 0,7 '62? t c7.cli f 5 1 4 '1 T ) 1 . (10 0 '/' 5 / — 5 l �6 f'S ( liii 5 cf q i -I , (---). ( 1 , ) , I I 'il r r / a' (1 ) c- .,5Z. /---h QQ 6 d d a`:7/ . 1 l/ 16 ICE POND DRIVE - LOT# 23 BP- 2004 -1085 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 37 - 113 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit # BP- 2004 -1085 Project # JS- 2004 -1618 Est. Cost: $267500.00 Fee: $1055.30 PERMISSION IS HEREBY GRANTED TO: Const. Class: 5B Contractor: License: Use Group: R4 GARY R CAMPBELL 073728 CO iki Lot Size(sq. ft.): Owner: DAVID A HARDY CONTRACTOR V Zoning: SR Applicant: GARY R CAMPBELL AT: 16 ICE POND DRIVE - LO° T # 23 Applicant Address: Phone: Insurance: 24 BAYBERRY LANE (413) 586 -9002 FLORENCEMA01062 ISSUED ON :5/11/04 0 :00 :00 TO PERFORM THE FOLLOWING WORK: CONSTRUCT 2 STORY SFH /ATT GARAGE /DECK /PORCH 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: } 8 — 3 't�"� ,// 42 , � n,�N� House# Foundation: © � � l _G 1 7 1 '''.--6-- ( v6✓2. ' Driveway Final: 9<Cwg4 la / dl0y. l Final: 2.. -f ,- 7 ' .`< Final: l (a? 4 )/v t- - AS 4 e Rough Frame: O K, /1 - ' it‘to ( vvsi' ris*:;4 Gas: f ((< 1 :0`4 U Fire Department Fireplace /Chimney: Rough: Oil: Insulation: t'� i / - /6- ` CLI "Q' X10 r inai: c 4 1 "' � / " � jmnice: o2 /{sfvs Final: P- �lD' 8�. -+� X70 O h THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. • �'Z Sig nature: .....----, /// Certificate. of Occupancy � _.__ FeeType: Receipt No: Date Paid: Check No: ` Amount: Building 5/11/04 0:00:00 10984 $1055.30 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo