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29-359 04��MP0 $" � +,�iasaac}rusetta ^l q - DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municipal Building . S,. Nortliarnpton, MA 01060 ,r HOME OWNER EXEMMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCNM 1083.4 to act aS his/her construction sup;:, .or. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two faini1y__- 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. r t homeowner 1_',__ L .7.,.. .--4',. / t rnt nt mt-lmn R� rrnc the I the homeowner hires other trades to pellVrm worn`electric-mll riumbirlb F,_.) 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 "; 1. ✓Jlu.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 /.2 / /rq -Address of work /location -:2 y i 'jA . �2_ �.O �✓c--fie,�y _--�_ o OEPARTMENT OP BUIL00\1C INSPECTIONS 212 Main Strect hTunicipal Building Northampton, Mass. 010GO `ORICER'S COiAPENSATION MSUURA-NCE rt1�IILf)A,Vj7•.. (Ii Jpcm;i cfcc) \vlth a principal place of businessfresidencc ac: (phone') do hereby certif);, under die.pz-ins and penalties of penury:, h:c ( ) I zra an employer providing the followinL'%vorkc's comocnsZ;io;: cove age for in) emplovees wor Dog on this job: (la5u-an=Conr,�) (PcLic: Ntt r) -- ( ;pirtior, D?L) ( ) I am a sole proprietor, geaeral contractor or ho¢-ieow-oer (title one) aBd have hued the cone actors (fisted below cvbo have the folio%vi�Q worker's coEiioeD-taaon pc!icies: (i+flIDe of Cont^eior) (I t1R!i�1. nC;L Compaq• -fiilGUc-, Namh<:) (Expilauop 1).11c) - (Name of CooEmclor) (1nsarancc ComoaII':lPoUc-, Nuimm-^-r) (-Ex pir Lion Date) (Name of Coanaclor) (Insurance (Expimdon Datc) (Name of Contractor) (tnsu=c-- Ccmraay/PoLcy Numb-:r) Daft). (nau3 ad.'lizocal 6c-- f acca. y to mead;infora oc pc to alas to.L coa=- -o:) { ) I am a sore proprietor and have no one worhdng for me. I am.a home owner performing all the work myself. NOTE:pl=.=be awut Th.,.{:.fie hca)=D very wto esptoy pc.cr=w do rgair work oa of ant mat th-n t moo-_ors in«'aim the bomcowacr rca�or oQ the Q-ou ,gpurtco_rs tbc-. ,ooc�orlty oa�:d,-cd to Lx cilployc-s uz,e—d---k=--C==p ,'m A�--(GUI 52.s 1(5)l by Fes' y t^pliabon n 6otneoava fer:!ice__a t� n-idmcx the Icgal ni sc of—arPloyo under tan Woricor.Coc:VOc a Act i mad tha a oopy of thi.-tL m av y b.foa--d-d to tbo C�pvtmmt of Iodussiel Aoadeatj Offioe of for t6. covcr'Z' vciLc=ioa-ad the C=Ium to"==bov,�uadc scctioQ 23A of).(GL 131 cia tcd to the iawaitioa of cimiaal pcan - eomi.ing of.fine of t�to S 1 500.00:ndJa o f up to ooc y--3r end ci vu pm.Puo n x form of.Stop Wort Ordc nod. fi=of S 100.00.day cpiaa ax- For =�uK only Permit Numbcr ..✓ �vt�... ? ';SSJ e',! N,(ZP. l.ot° is S�tcun of icscc/PcctnitCc� Late, -- i Y SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9_:Registered"KbrneYmproverrient:Contractor " Not Applicable ❑ Company Name Registration Number -- --_ Address Expiration Date Telephone SECTION 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...... ❑ 1 I .Homy Qwne>l-�Fa��>l��i�a % The current exemption for"homeowners”was extended to include Owner-occupied D:yellines of one 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 orthampton 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 D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[o] Al"rief Des�ption of Proposed f ) l J r Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa If New house and or adcf tiag to extstlnkti hausina comatete fhe foFfQWFnq: 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'Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR 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 OwnerlAgent Date , , ~~ � Section 4. ZONING All Informatio'n Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filIed in by Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved (volume,,&Location) ' A. Has a Special Perm it/Varunce/Rndi ever been issued for/on the site? /~~� v~� �~� � N0 �� D�7K�� �� Y� �� IF YES, date issued:. / IF YES: Was the permit recorded at the Registry of Deeds? NO D0m7 vu, IF YES: enter Book Pogo and/or Documonc#� ' - �� �� B. Dues the site contain a bouuk, body of water or wetlands? NO �_��� DON'T KNOW �~� YES ��, IF YES, has permit been nrneed to be obtained from the Conservation Commission? Needs to be obtained �_� Obtained�~� on /—\ 'Oa�m Issued: \,~/ ' � ' C. Do any signs exist on the property? ��� YES �~/ N0 t_� ' 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 0 ' |F YES, describe size, type and location: ! E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre nris it part ofo common plan that will disturb over 1 oono? YEG K ) � NO K ) _ ' _ IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ' � a __-...---City of Northampton Statu�ot P�rm�tt ; 1ldin 4 � 1 Cr�rbCmt�DfiyewayPermit �yY� g De partment 1 ( Cn �12 Main Street SewertSepticAyailatstlfty . . - �. Room 100 W`6tbtjW'6I'Av. I bility ry ^� No_rrinpton; MA 01060 TuvoSetsoStructuralPlans `phone 41 -58711240 Fax 413-587-1272 P[ot.Site Plans � Other Specify APPLICATION TO C'ON. E-T;ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION' 1 Property Address: This section to be completed:by office Lot' .Unit. one., .' Overlay District. Elm SL District CB District SECTION 2-PROPERTY`OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of/Record: A Name(Print) Current Mailing Address: 13 -5 8'y--g3tis Telephone Signature 2.2 Authorized Aqent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED'CONSTRUCTION`COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant . Building f ,75. �� _ (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building,Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number > This Section For Official Use Only Date Building Permit Number. Issued: Signature: r Building Commissioner/Inspector of Buildings- Date 243 ACREBROOK DR BP-2005-0684 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-359 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: woodstove BUILDING PERMIT Permit# BP-2005-0684 Project# ]S-2005-0926 Est.Cost: $175.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: Homeowner as Contractor Lot Size(sg.ft.): 15028.20 Owner: MURPHY TIMOTHY&KATHRYN Zoning:URA Applicant: MURPHY TIMOTHY & KATHRYN AT: 243 ACRBBROOK DR Applicant Address: Phone: Insurance: 243 ACREBROOK DR (413) 587-9375 (� FLORENCEMA01062 ISSUED ON.12122104 0:00:00 - TO-PERFORM THE FOLLOWING WORK:INSTALL WOODSTOVE 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: FinaWk THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI OF ANY OF ITS RULES AND REGULATIONS. ;7 M Certificate of Occupancy !,? Signature: /VUU FeeTVpe: Receipt No: Date Paid: Check No: Amount: Building 12/22/04 0:00:00 16$3 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo