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11A-059 OQ-�HA1NP�0 Grif r of Xarf4ain ptan � z �11 itSSRt}�liStttS ^ - -, DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municipal Building ' Northampton, MA 01060 r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as iris/her construction sups; ., 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 family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one hume 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, 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 y L G1 1h7 of �Narfl?alllpf(111 . ' ��11l Sa R(Ii Ii6(tl5 T m DEPARTMEN-T Of' BUIL.DP? G INSPECTIONS 212 Main Street ' Municipal Building Nlorthampton, Mass. 01060 WORKER'S COMTENI SATION I SURANCE AA i M ANrl-T 1, v pith a principal place of businesslresidenc- rStTcct/cll ';: -..--- dO 11CI"CUB' CCriLIti', tlll:'cl" L}1C p<ai1S ?.i]d pCi] ii1CS of pC.f�ilr�t i11al. I aril an criaployei- providing the iollovvirlC '.:0!"r;Crs colnpcl]snon coverr:'",,e For '11), cluplovees worl•.ing un Lhis job: (In =aa Comm-) CIic: (r}pir,:lion Date) < ) I act a sole proprietor, general contnc`or or hotneovrcer Ic'cle one) and t:a`,'e cured die,, contractors l.ste,, beicry v,-ho the rOilG .P v of ker`s comuD n-?nrl (Name of CO 1Ia iGr) I(rissu incc Nu3Tlt--r) T '• :a.:,C' Date) (Frame of COPIT?clor) -- (11�d >ncc Comp rwPe!ie,' Ntnrr r) ( ,:psraiioa Date) (NIame of Contractor) — (In;r nc� Cou;'L;iPolic. Nutill, r� -x; r. r:c,c Dat,) - ('Name of Cont-actor) —- (Irullranc Comm_'y!Po1ie; hrumb=r) (r;;:r, -:ao Date) (- 1 il171 <t OIC pl"UpI1CLC)i <ii11 haVC I10 OI13 "•1'l;r�.Iii ' t07 -mc. I mill a home oVJI1C� i)Ci"IC I]11I�` all i'_: '�'• iIi` if >ioTl::plcnat be AwDuc List si.lc Ix<rco tzrra a:o e p!.� ;r.. n::>:_� :uac�cz::n m cs:;?a r •,:i::r_ ..cl!i.:, not ux,re th n throo uiti+_j in t L ct he I rc:cLcz o-a;L �;:;� fir• r cr rS thcro a c n{ecrrall, a :::.:r.': F. eZ ployc3 uzr'�t tIr tw;i;J'c cc x•=::'i^r.,tr.(GL!.`2 1(Sll, c:;'vy homcow:w:`or e L -c Cr .-.,. legal Ltatut of an c 3ployer unu' tL•o Wo k"; t io tr o atian�.eL I unde--xta d Ilia!a co?y of qv maters_:c:.y bo fo,tivnrcte:l to v»I}cji un—e oflndu, -Tid A,6"d ty C=rew of i:a.cr =.e for t!x eoverxse vcif anti oo and that f_iltuc to!-^ c coti�t M uI 3: c�,ia 25 A of MGL,152 can lmd to the imrNnitio c f r it l pe al;:s cvmiuting of a fur_of up to S I-SC0.00 an:V or i^:;tri r.z :1 of::?to cr.:}t ..:.1 evil perualtia in do fc-,nn of a Str. fry oCS! d+y 1 ' tom'-•-..,_. --------- --- -- `- •`� \\ \� Pcrrnit ------�+-- - ,tit ------ -,� _ —_. :t•,;l t Jrrnnture cif i.iccar- r.rr ;ar--; -�,+ ', II S CT�NT8 YCaNSTRUCTION:SERVICfS ]31 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone f1e rrt• �em'en ontrac _ Not Applicable ❑ Company Na a Registrati n Number Address ExpirlttionlDate Telephone SECTION 0 WQRKERS';COMRENSA,TION-.1NSUF3ANCE:AFFIDAV.IT(MG.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...... ❑. {I. n 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 acecptable to the Building Official,that he/she shall be responsible for all such work performed under the buildine 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 I SECT1.0 - 5. F� lflt+ F ROPOSED W ORKS cl eck � Ijcable . New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Sido in [ ] Other [ Brief Description of Proposed Work: �i �!itvl Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0- Sheet 0 6a,, eanr o 0 favaBd it of nitO�e,iS ing tt uo sing c-,-0 pet e. °he fo11V-n 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. Mascheck 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 Nc 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 SEC0 � Ui��R[ZAT10N TO BE COMPL'E TED WHEN DWF{S E r 000NTRAC70RAPPL1ES FOR 17,15 UILDING PERM17 �M v — � S Owner of he subject property hereby authorize to act or my be alf, in all matters relativ to work authorized by thi wilding permit application. 0 - 0 Signature of Owner Date 1. © � as Owner .Authorized Agent hereby declare that the statement and information on the foregoing application are true and accurate, to t e knowledge and belief. Signed under the pains d penalti s of perjury. Print Na Signatur of OwnerY�A. Date 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 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 parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/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 Conservation 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 1F-YES, describe size, type and location: City of Northampton Building Department n �n � 1 Main Street i1 V Room 100 No pton, MA 01060 NOV P1 9,. No 1240 Fax 413.587.1272 A J,�t GTIQ$=1t 7RUC , ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING N . SECTION 1 - SITE I,NFORIYIATI,ON sgsectio toy", : om ed .yoffice "z , 1.1 Property Address: WS-) V.) Elrr��St Duct .s CB Dis r�ct SE C TION-2- PROPERTY=OWNERSHIP/AUTHORIZED AGENT. 2.1 Owner.of Record: `` v y`ni � �o� � ���� - . IMF Name(Print) Curren Mailing Address:_ Signature 2.2 Authorized Agent: Na e Pr, Current Mailing A dress: _7 Sign ture Telephone SECTION=3' ESTIMATEC:i'CONSTRUCTiION'COSTS r- Item Estimated Cost (Dollars) to be Official Us0ADnlY completed by ermit applicant 1. Building (a) Building Perm'it 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 + 5) C�c� q tj Check Number This Section For Official Use Only Building Permit"N'umber: Date Issued: Signature: Date Building Commissionerhnspector of Buildings 107 FRONT STY BP-2005-0595 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: l 1A:059 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-2005-0595 Project# JS-2005-0791 Est. Cost: $8250.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: THOMAS DWIGHT 100524 Lot Size(sq, ft.): 42950.16 Owner: SCHIFFMAN LAWRENCE S&SUSAN V Zoning_URA Applicant: THOMAS DWIGHT AT. 107 FRONT ST Applicant Address: Phone: Insurance: 27 MAPLE AVE (413) 584-2138 HADLEYMA01035-9710 ISSUED ON:11116104 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 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• Receipt No: Date Paid: Check No: Amount: Building 11/16/04 0:00:00 1868 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo