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29-313 (2) 70.64 fee E o W d : a a _ N O O] Ljj n 2 EL ( _ Uf \tD z ' 142•�� 4 33 20 W t I N 33 to picket fence N _ W d > q & r--1 1 Jo o 0 Y O w � W O L1: � �12 m o W °' � z tO Qz CL c Q � o d w . � 102.56' Jr ❑ S 33'33'20 M , 1�1 it35RCl'1[S[tf4 r _ of Narthaniptan DEPARTMENT OF BUIIDIT;G 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 has/her construction supt.: ,' 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 fancily 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 rouzh 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 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 �5 c� a i OQ--(tt/.J-!PTO Gr�3ia � B f $2aaaarhncclla' _ i — r DEPARTMENT OP BUILD0\10 INSPECT101JS d< 212 Alain Strect Municipal Building Northampton, Hags. 01000 ,i WORUC:R'S C0iYTENSA-n0N MSUaA_NCE AFFMAV1-1- 0i 0M&-_&perml tfcc) with a plir2cipaJ place of business/residence at: do hereby certify, under Cie pp-ins -rid penalties of perjury.; hat ( ) I am an employer providing the followine workcr 5 comoens:do, Cove-- ;c for Iny emplovecs worLong on this job: i (lns,=_.ncc Comr„_m) (Pclic; Numir_r) -- (r:•pirtior, Dart} O I am a sole proprietor, general cooa-actor or homeowzter (a_cie ore) and have hired the contractors listed below wbo have the following worke> s com sa n pa!icies: 0"+1112]: Of C0:=Ci0") (IIIRIzIIC: COiTIt)1,"1)-1.2 GUCi NIilII1tC:) (Name of Contractor) (U siu-zncc Comp zwPol.ic Nurmcrr) (D»triton Dme) (Name of Co nn-aelo,) (Laaa-ancz Compaoy/PoL-q- Nulnbu) (Expir,:tioo Daic) (Name of Coaaaaor) (Insuran(-- Company/Pobcy Numbc-r) (Expiration Daft). (ao-acb:d•!i;:oc�l rSca.if aceezary to c,cud;infora,i^i oo pe-L.�Lo'U { ) I am a sole proprietor and have no one working for me. ( ) I am.a home owner performing all the work myself. NOTE:plt=sc be eortrt tti,.�i Se homed�vcn Sabo eraptoy Pcions w ea_.;e.,00 c rcaair..-ori on.d-11--Z of GO(anon than LbTM ter.,in ta�the bomoowncr raid=a oa the Qound:,z-,717 ao_r1 thcao L nx -lty occ,:d=-d to be eitpioycs untie the,.aS d;oc,�- .,:�Act(GL152=I(5)�:;vUnt6oa by a bomcom-D t fcr_Gem.or p=mh r=y c,7&0-trc j1­5J rtanu of an.s�loyer under d,o WorSC.ola Cort�emation Au.. I uadct%A. d d,a a oopy or this ast®cm may bo food to the Dopartmcot of I.&tuial A_d wy 0M_orI,aa—for tha e0va-esc vt=:Lc lioe a-',d at-_t L-l=-c to scutrctvvnry�tndcr soaion 25A of h{OL 152 m led a the i Trion ofeimsosl pcosltics COOStIISg of i riDC of t�to S 1 00.00 and/or i=xPriy0p=c=or up b ooc Y=r end civu p=ane in to form of a stop wort OHcr and a fi=of S I OO.DO a d_y=Foust me For dcp.rtaa:-sl u.c only . Kermit l`t LLmL--r Lot n SttP-1curr of LiccnsrsJPcrmiucc L)Bte ) f SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9�Reaistere om #mnravemen#Contractor "' ;2 Not Applicable .❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCEAFFIDANIT(M G.L.c.1"52,§.25C*) 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 erson who constructs more than one home in a two- ear 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 Ordinance e and Local Zoning and State of Massachusetts General Laws Annotated. Homeowner Signature r e SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alterations) ❑ T ofing ❑ Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks M Siding[O] OtherA"p Brief Description of Proposed Work: , Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet salf7euhorseando cI'iiortcrezr'sting,.hacirticr,omptCieotfaina: 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 cod struction 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-OWNE,R AUTHORIZATION-TO BE"'COMPLETED'WHEN OWNERS:AGENT'OR'CON.T,-RAGTOR-.APPLIES.FOR=BUILDING-PERMIT as Owner of the subject property her authorize t act or?my behalf, all ��rs relative to work authorized by this building permit application. Si ure 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 Section 4. ZONING All Information 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 A0 Pno Frontage Setbacks Front Side L: R: L: a� R: l�0 Rear y Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking S aces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO © DONT KNOW © YES O IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW O YES O 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 0 IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 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 O NO (,'Z- V-1 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. • •.i Department use only City of Northampton Status of Permit: Building Department Curb CuttDdveway Permit 212 Main Street Sewer/Septic Ava#abi'lity Room 100 Water Weil Availability Northampton, MA 01060 Two Sets of Structure Plans phone 413-587-1240 Fax 413-587-1272 PkWSite Plans Other Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be completed by office 3'� q I , Map Lot Unit 0\0 , Zone Overlay District C Elm St.District CS District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Na rint) Current Mailing Aid Telephone X11 %:iqn e 2.2 Authorized Accent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by rmit applicant 1. Building (a)Building Permit Fee 2. Electrical p� (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 Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date t sw to File#BP-2006-1327 APPLICANT/CONTACT PERSON SADLOWSKI CAROL&DAVE ADDRESS/PHONE 334 Acrebrook Drive Florence 586-2286 PROPERTY LOCATION 334 ACREBROOK DR MAP 29 PARCEL 313 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out _ Fee Paid ZPf T_ypeof Construction: INSTALL 24'ABOVE GROUND POOL& 10 X 12 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO,YMATION 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 Co� 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. 334 ACREBROOK DR BP-2006-1321 GIS#: COMMONWEALTH OF MASSACHUSETTS MM:Block:29-313 CITY OF NORTHAMPTON Lot: -001 Permit: Building Categoa: BUILDING PERMIT Permit# BP-2006-1327 Project# JS-2006-1959 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 10018.80 Owner: LAIZER SHIRLEY A Zoning:URA Applicant: SADLOWSKI CAROL & DAVE AT. 334 ACREBROOK DR Applicant Address: Phone: Insurance: 334 Acrebrook Drive 586-2286 FlorenceMA01062 ISSUED ON:61912006 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL 24' ABOVE GROUND POOL & 10 X 12 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:yf �0 Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final:c i< THIS PERMIT MAY BE REVOKED BY THE TY OF NORTHAMPTON UPON VIOLATI N OF ANY OF ITS RULES AND REGULA N Certificate of Occu anc si nature: FeeType• Dare Paid: Amount: Building 6/9/2006 0:00:00 $25.00165 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo