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29-123 (7) r 9 � j�'ilassxchusetfs n s g own• DEPARTMENT OF BUILDING INSPECTIONS /_ f INSPECTOR 212 Main Street • Municipd Building '>o North,-unptnn, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as has/her construction supra_ 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 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, 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 0.q iVJ•f p2. , F20 Ii3 ref �crrfl�aiit}�tott _ A E �.sanrftntrtta• DEPARTMENrT OP DUILOD�G INSPECTIONS — ' 212 Alain Strcet ASuaicipal Dullding Northampton, Maes. 01060 W0R I:IZ'S COWEPENSA nON L'ISURANCE :�ITD�:i��i�' - \Vith a principal place of business/residencc at: 1 • I it �t- r lctr�'✓k� �.. Ul f' �f�m! r (sa-�t/city/stalrJa p) do hereby cerdfy, under dic pains and penalties of perjury:; :hat ( ) I am an employer providing the followine worker's coinocnsZ:30 P, cove arc for u» elnpioyees worlong on lilis job: i (Insure Conn) (PCUC-, ?�umbcr) --- (r:pir.•tior Dzrr) O I am a sole proprietor, geaera3 contractor or homeow-Der (cl cie one) and have hired the conu-actors listed below wbo have the follotvm* g workers coLoePsadon policies: (i+QIDe Oi CORr^Ci0') Ons-uranc^. Coinpa iyPiobCi ?��ua1^C:) EXJLJOQR D fIC) i (N'-me of Cooa-aaor) (U1Sw-0cr Comoa.nyfPo!im Nu.mc^r) (EaDir tion Dale) (Name of Coalraetor) (Insurance COmTun)-/PoUq- Nambu) (Expim6on Date) r (Name of Contractor) (Insuraac–_ Company/PoUcy Numbzs) (Ekpirriion Datt). (.uac� d! cScd.irnccti s+_}cc mdudc Laror=azioo pons=ns to.0 oev s) (' I am a sole proprietor and bave no one working for me- ( ) I am.a home owner perforTning all the work myself. NOTE:plr-..be ew2rc t s .{ja hem vcra�bc employ pcwm w c• -• c=_—zcwo c rcpzu-ork oz a d..<it:-`of aot meet tl, ttzoe t y�is w'ye6 ttx bom..w r mid,.or oa the p-ounF�zppurteal7 the en r we Cer_.tty oo= =-ci w be enploycs uae a the..ui et=o Lca An{G Lt 52,=I(S)� =,pptinbon by n bomco ac=fey c Gc _or perma ra=y c.rdm tL` 1c 9a cta3u of=c:lloyx wader dh W orUeL Cori Ad I�sadc*uad tha:oopy of this catamcat m.y be for-, ,d d to the D p tm.w arrnd. ,j A—d.WY OfG-or Iru+r.oc Jr-the cov—cc vaiGavioe and tlu L-,mr to to=m toverase ut�dct soctioa 2 3 A of hi GL 152 as Icd to the impo:1 ioa of cimiwd Pc—W eoosizaig of.S=or up to S 1300.00.allor orup to ooc ytir cod coil pm.I-ia in tx form or.Stop Work Ordcr.ad a rte of s 100.00�d=y.¢;an tt�c - only --- - PCrmrt Numb= _ Lot " t usJPcrntiucc Ce SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑Lf 10 Name of License Holder: �� �n-M���H (��1 License Number /14 /00 4, 0-7 Address Expiration 6ate Telephone 9 Reaister�d'Homeiriaar"oiemeratontractor, r Not Applicable .❑ Company Name Registrati n Number Address Expirat n Da tfi 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...... ❑ in 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 r > e 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 [O] Decks [M Siding[0] Other[C� Brief De .ptioQ of Propose Work: l C =7p cryX `�'°' '� 6 txe Alteration of existing bedroom Yes No Adding new bedroom Yes v No No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa 40'14`6"W"',h A ouosedo exsnr�o5 �orrq: 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 7a;-OWNER.AUTHORI4ATI.OW-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR'BUILDING PERMIT' as Owner of the subject property hereby a hodze to ac on y behalf,in all rs relative to work atithorized by this buildinVj/applic ion. c Q C, Signature of Owner Date 01 y r ) 1 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. t%1 L !i� Print Name Signature f LwA�� 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 Frontage Setbacks Front Side 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 a6/cial Permit/Variance/Finding ever been issued for/on the site? NO DON7 KNOW 0 YES 0 IF YES, date issue L IF YES: Waise permit recorded at the Registry of Deeds? NO Do N 7 KNOW 0 YES IF YES: enter Book Page' and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 Date Issued: C. Do any signs exist on the property? YES 0 NO 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 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading ation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO It IF YES,then a Northampton Storm Water Management Permit from the DPW is required. L pity of Northamptonasof Fs3ullding Department X212 Main Street ; — Room 100 I rj Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE-INFORMATION Tfi�s sect�oc�to be completed by office 1.1 Property Address: = Mapt Unrt* Zone Overlay i3rstnct ��rt�tc 1`'A_ ©tOcDQ- Elrn St k�strict C6 Distuct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED'AGENT 2.1 Owner of Record: _ - 1 L�UC [�L 12 C�t �.� `7 Al-i Nam (I nt) Current Mailing Addres Telephone Sign, re 2.2 Authorized Agent: _ Name(Print Current Mailing Address: d�C}'� Sign Telephone ECTIO NOF-EgTIMATED CONSTRUCTION`COSTS- Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building [/ (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=(1 +2+3+4+5) , Q� 00 Check Number This Section For Official Use Only Building Permit Number- IIs ssued: Signature: Building Commissioner/Inspector of Buildings Date 3 w BP-2007-0164 GIs#: COMMONWEALTH OF MASSACHUSETTS +?- _ '1"T` CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2007-0164 Project# JS-2007-000243 Est.Cost: $3450.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JESSE MONTGOMERY 134274 Lot Size(sq. ft.): 10890.00 Owner., BEREZIN ILENE Zoning:URA Applicant: JESSE MONTGOMERY AT. 441 RYAN RD Applicant Address: Phone: Insurance: P O BOX 329 (413) 585-8482 LEEDSMA01053 ISSUED ON:811112006 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE GARAGE & SHED 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• Date Paid: Amount: Building 8/11/2006 0:00:00 $25.001275 1275 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo