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J \/i n sit'' '� - _— _ - 410i- 1 l f a en al „93 r . 9 r i f d � a tr � , _ ski 3 0021 On z �,� sl t �� ��n ate) ans r4 ,tvr� ?—j> �)nd tiw ; _ a � JI �l � °IoU r 1d x e 0 l 141 o€' Ive © iv orl e'AQjV ) D' 0..3 }s. y2soa� ea/ (Y(Yl A 9 9 Lid NOLO V14 Atka s citiAMp i , O O �� �` , C rd Northampton � ^ = * =4 . ■� a l t Z $� ,��n rah 7 s -_pl � « Iassaclyusetts —1 DEPARTMENT OF BUILDING INSPECTIONS _ / INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 o,~ S`, ` 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 sup .' Sor. The state defines "Homeowner" as " Person(s) who owns a parcel on which he /she resides or intends to be, a One or two fron ly - ` 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 fegulations. 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, 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 r 1 • -cttAttn?. f o N I V y y�`iE ' giii of Northampton 1 ■ 2_ . q ( 3 ; cyanchnsclla' Q - DEPARTMENT OP DUILDf ' G INSPECTIONS 4 i 212 Main Strcct ' Municipal Building j Northampton, Mass. 01060 r WORICEI 'S COMTENSATION G`tSURANCE AFTEDANM' • T -- — - _ (Iict nscCJpcnnittec) — with a principal place of businessfresidence at: (phone:') (sa=/ciray /na ch p) do hereby certify, under tlie.pains and penalties of perjury, :hal ( ) I am an employer providing the followine! worker's compensation coverage for my , employees worming on this job: ,, Or us = Coaczny) (Policy Nu.mbcr) (r xpira oa Da") - I ( ) I am a sole proprietor, general contractor or homeowner (ciscie one) and have hired the contractors listed below who hive the followine worker's comoensadon policies: (-Name of Con'.mciwr) (In.uranc:. Coino iyi oUCi Numixr) (F_NpmJ:?on Da lc) (Name of Con (Lasurancz ComoaayPoLicy Nuuicrr) (E»iration Dale) , . • - (Name of Conuaao ;) (as :10 Compan Nacebu) (Expiration Daic) - (Name of Contracicr) (Lanuanca Comcau m y/Policy Nn,b-•r) (Expiration Dale) . (an.ah sd1.17ioca1 bcc ifncccL.�t-to atop& informadoa pcvunias to all cow- -tv:z) . (4 I am a sole proprietor and have no one worli3ng for me. ( ) I am..a home owner performing all the work myself. NOTE: plcse be &P.-arc tt!at while homeowners who =ploy pcz.oal Lo do r -,;,--,--, ,-,-.= cr.:uoo c rgau Boric on a d.. -cii of not mom then ttstoo t=its is t•3ieh the bow we ra ido et oo the p-ours agpurtew-at tba-oo e.-r roc c=c-.Ry arr'd. -oi to to enploye3 u=Ccr the waicotz o=cp. • . , ion An (GL 1(5)). rpplinaoa by • bomooaaa fez a b - ' a- permit cozy e,•idrnee the logs..1 mate of ea =3;31 o y c uadcr dao Wockcra Compwn,tion A. I uodastaad the a copy of thin catcmust may b. (or-Nerded to ch. Dcpartmcaa of I --rid Aacdcrt3' thine of I u'ooe ror th° eovtsa.sc vcriG. iaa and thst ant= to so urc boverase =Act 3.oC ioa 25A or MOL 152 osa lad to the i asaioa of tsimiasl pc coositing or a fine Drop in S1,500.00 and/or i=prisocoacat of up to oac yt. r end civil pma tier is t x focal of • Stop Work Order end • fii3n o(S l x10.00 a illy cptin4 ox. For dcp.na' =-sI u.c Drily Pcrmit Number I 1 �' f ' . ��(� _ 5 Man= —_ Lot " .—.—� l r O Sivnat1r of Li cn cciPcrmiucc Uste . - -J A • SECTION 8 - CONSTRUCTION SERVICES 1 8.1 Licensed Construction Supervisor: � [ Not Applicable ❑ Name of License Holder :_ JGL4 t . \ �VD Ue I I e Q'S Y 7 Z "!- 7 License Number 144l s (CAL(' 12,4 to C (e 4 (4/1 61 CVO 17 3 G I - 7 - C.) Addres Expiration Date _ ?mot I) ( be-A q q /k Signature Telephone ,CFeairs1"ere"r i fia ei'ael 'o raera�r ;„;. `" ., ,. ' Not Applicable ❑ ]7 ' ( �4'�. ((e f to • /0.2-0 Company Name Registration ii er 44' �44f--is e ' e L l G" . _3e 06 Address Expiration Date Telephone Y13 4 S / /c= SECTION 10 WORKERS' COMPENSATION INSURANCE. AFFIDAVR (M.GL. c • 152,125C(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 131 c e tl (a e e 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 r SECTION 5- DESCRIPTION OF PROPOSED WORK (check altapplicable) New House ❑ Addition ❑ .; Replacement Windows Alteration(s) ® Roofing El Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [O] Other [0] Brief Devription of Proposed � ' A!C'u� �Oe � � I Work: %ktsktvnct Sc..re pct to be c��►C�r1 - 4. le e; r f £�� U rc Alteration of existing bedroom Yes >` No Adding new bedroom Yes y No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet - r ' ' ; �K '*°t^� ;*r- "!"n:%%�'�"c, :X =`� �*�:, '�. 'te « �+tt 6a-. € eW�ra s��Inc r .ctc c a " exl tfiWt t e ICr .co 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 stones? 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 AUTI kORIZATION TO BE COMPL'ETED -WHEN OWNERS AGENT: OR CONTRACTOR- APPLIES FOR BUILDING PERMIT 1, MAK I My OVA , as Owner of the subject property hereby authorize 14 to - „Dec lte to act on my behalf, in all matters relative to work authorized by this building permit application. Signatur Owner Date • l id � � (1 l 14/ , as Owner /Authorized Agent herelydeclare 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. M 4 itt Print Name j, : �c�n , J S Signatur= :f Owner /Agent Date Section 4. ZONING All Informatioh 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 ' fa5d I { if Frontage 5 b ' Setbacks Front , Side L: E R:' 'L:1 1 R:i Rear I [ i . Building Height , . 101 Bldg. Square Footage t � 6 I 1% I 1 I j Open Space Footage (Lot area minus bldg & paved i i i parking) # of Parking Spaces i, a- I i I Fill: r l i I (volume & Location) i 1 A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DON'T 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 0 IF YES: enter Book Page a and /or Document # B. Does the site contain a brook, body of water or wetlands? NO ;f DON'T KNOW Q 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 Q NO 0 IF YES, describe size, type and location: j i D. Are there any proposed changes to or additions of signs intended for the property ? YES Q 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 Q r NO � i IF YES, then a Northampton Storm Water Management Permit from the DPW is required. '` \ ' it,of Northampton +at , � - �' Q Buifdi 99��,,Department � f' �; f) / C, 21 in Street , , � !� `, %% Room 100 ®, �, Northampton, MA 01060 s y a ; pho 13 $c7 .1.240 Fax 413 - 587 -1272 � � t, �, „ \ ,\ S IB APPLIC aN CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 $ITEINFORMATION I 1.1 Property Address: '* °" Ti ssect�or> -t be compt"etedby oWce // mo w. -..,p f , i". I C � I ezt ,-,..1., Si Lot tlnff Alit .. " 144 A 4Yone Dverlay Drsfnct. E 4 ' IC D c,. SECTION 2 - PROPERTY OWNERSHIP /AU 2.1 Owner of Record: j /� / / /� �j Mai' '''t C vl / 6 U te4- -50/ 1 ° t 4 d1 "`�"e w�?�s�yj �' it Name (Print) _ Current Mailing Address: q 13 Telephone Signatu 2.2 Authorized Agent: Name (Print) Current Mailing Address: Signature Telephone SECTION .3 - ESTIMATED - CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building / 4 „©( '+ (a) Building Permit Fee 2. Electrical (b) Estimated Total fro Cost m (6) of 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total= (1 +2 +3 +4 +5) Check Number I This Section For Official Use Ony .Date.. Building Permit Number. Issued: Signature: r S a�0� Building Commissioner /Inspector of Buildings Date � a "fix :�� rZ.- a" • 19 GLEASON RD BP -2005 -1223 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 18C - 099 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit # BP- 2005 -1223 Project # 3S- 2005 -1641 Est. Cost: $14400.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Daniel Drollette 072267 Lot Size(sq. ft.): 7492.32 Owner: FINN MARY MARGARET & MARIBETH Zonine:IJP1 Applicant: Daniel Drollette AT: 19 GLEASON RD Applicant Address: Phone: Insurance: 49 Masterson Rd (413) 665 -4818 WHATELYMA01093 ISSUED ON :6/9/05 0:00:00 TO PERFORM THE FOLLOWING WORK: ENCLOSE PORCH, REROOF & NEW ROOF DECK POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: �� /G � Footings: Rough: Rough: o S r House # Foun dation: pl Driveway Final: Final: Final: f jwj1 1�1' �! Rough Frame: 6 y- ` b Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insula it "ons Final: Smoke: Final: P 11- 'THIS PERMIT MAY BE REVOKED BY THE CIT • F NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIO S. Certificate of Occupancy Si . nature: FeeType: Date Paid: Amount: Building 6/9/05 0:00:00 $60.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Building Commissioner - Anthony Patillo