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29-120 (2)
,.City of Warts amptan L $ � I�asaacf�usetfs r - �-, DEPARTMENT OF BUILDING INSPECTIONS _ INSPECTOR '212 Main Street • Mmucipal Building '>a�44 Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as hds/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 famity-- 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 r j 0 4zttn rn�o „a e (fiiiL Of AJ E -qZca•i<chnrcIIIs Q OEPARTMENT OP BUILDI\1G INSPECTIOt.'S — 212 Alain Strcct ' -Municipal Building Northampton, Mass. 01060 WORJ:CLR'S COLAPENSATIO.N MSURANCE AI<I'MAVI-1- (I I cciL xlpcm;ttcc) ,Inth a principal place of businessfresidence at: ---- - 1 :- (phone:-) /3 (42k •/ p) do hereby ccaif--, under dic.pa_int znd penalties of penury:, --hat QO I aln an employer providing rile follow- in-, %vorkcrrs comocnsa:J'on cove age for 111) e(uplovecs worUng on uiis job: i 7 (Iasus-:nc Compi v) (Policy Nu-mix-T) D2jc-) O I am a sole pronretor, general conaaaor or homeowner (ci tie one) aad have hired the cooiTaccors listed below who hive the folio%viog worker's col nen_sation pokles: (iIjalDC Oi CO2t^cwr) (Insur-3nc.CoInpan)-il�ouc ?�r11Z71�Q) :J1idL•Q?D IC) (Name of Cooaaaor) (Insdlancc. C-omoaII aPol1C'i Nunccr) (Ex—D ion Date) (Name of Coaa-aad,) Clasurancz Company/pobcy N.,mbt.r) (Expirz600 Date) (Na-Mc of Coancior) (Lasurmcc CompaQy/PoLcy Numb`r) (E��irtion Daly). (eoac3 'ts�oca.l�cC.ilncca.a_p to atcuinlonni'ioa pcttaiaias to.11 O I am a sole proprietor and bave no one worldDg for me. ( } I am,a home owner performing all the work myself: NOTE:plr-«be Marc t5„• Q-e bemeo..vcn_bo crnPlay Pte—oC=to dD =c c=s,:rjoo c rcpair work on a d„cI1LL of ant mom th:a t` -tiara is W� Lb.c bomoownc raider«oo the Av tai t zppuricuarl tbeeo Lc oot Cxcily cots d -Cd to be cz>ployer on e the..ui�=cam-- ,,Act(GL'i 52-=1(5)�=PpUci6ca by a bomeoava for a(icy__a pc=it t=y evid=-the legs.!etaau of as ezployer wader di Wcrkc e,ComP•vmu O Ad I uvdaza+ad tha x-OPY or thi.—I—may bo flur i d to d,Dop"rtmr_t of In�+Xrial,,ccecaiY OT,—or try ur..oce for tb< Dover ibc v0 ri Csioa and ttu L-i=r to smut bovcry�tmdc 10e oa 23A of I,(OL 132 caa led to the i�xsitioa ola mia�!peaittia ooaitsiag of a riot orttp to Sl}OO.OQ artd/«im{truooa�eri o(uP to roc ycr t-od ci%il pmutia is dx room o(a Slop Work Ord=nod a rim of S 100.00 a day agaiast me For dW'rtrx'1,t u.c Derry t crmit Number A/;�� -- 1Y9,41 i,.Jap.' Lot tun of i crr:tittcc f SECTION 8-CONSTRUCTION SERVICES J•• 8.1 Licensed Construction S ervisor: Not Applicable Name of License Holder:�l/ �/!/�, �� l © &,-3 eicense liumber 'e � drG3 Z�� Ac1dress l Expiration Da e ignat re Telephone 9 Re" sfere Home` raverrte Con rac or - m: ` Not Applicable ❑ Companv Name Regis ration Nu ear-----"------ Addre �` Expiratio ate Gtf' °YO TeIephon —/ SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G:L.c.152,,S 25CM) 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)fatuities 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 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 r a q SECTION 5-DESCRIPTION OF PROPOSED+WORK;(check all applicable) New House ❑ Addition []:; Replacement Windows Alteration(s) Q Roofing E] Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other(C7l Brief Des ti of Propo Work: Alteration of existing bedroom Yes No Addi g new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sax If'Nev�`�o>i�se}and�c�rdditiO�r o�ex>lst�r` .6ousin fR�arii" fet��he��fot�o�r� ": 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 AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR"APPLIES 1=0R'BUILDING PERMIT 1, 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 Mereby declare that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. rint Name /d2ZO t-cqnaturj(of Owner/Age t 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 Frontage -- i Setbacks Front Side L: R: L: R Rear Building Height i__ i 77= _- — Bldg. Square Footage i % �i I Open Space Footage _..—_, % (Lot area minus bldg&paved arkin l #of Parking Spaces Fill: (volume Bc Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? N0 Q DON'T KNOW 0 YES 0 IF YES, date issued:! IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW Q YES 0 IF YES: enter Book Page;; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T 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 0 IF YES, describe size, type and location: I D. Are there any proposed changes to or additions of signs intended for the property? YES 0 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 0 , NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton o ,.wilding Departmenttti �awa 212 Main Street Sever p r alt t� Room 100 � �� Northampton; "MA 01060 p S�s. str 'ans e ', "7 hone 45$7-1240 Fax 413-587-1272 PlotiSlt t�ans. � � CthBr7eCtfjf ` APPLICATION 1TQ'CONSTRIOCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -.SITE INFORMATION 1.1 Property Address: Thrs section,to he compfeteck byoffce Unrt Zone Overlajr';Drstrrct to tie�� "Eth St:Distnci CB D�stnct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature G / l? 2.2Authorized Agent 147 L 4�i R/j( Ild AGLI-#,V �2 e.9, (Print) urren Mailing A resx ignature elepho SECTION 3.-ESTIMATED"CONSTRUCTION COSTS Item - Estimated Cost(Dollars)to be Official Use Only completed 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) Check Number Jc- This Section For Official Use Only Building Permit Number." IIsssued: Signature: Building Commissionedlnspector of Buildings Date 70 FOREST GLEN DR BP-2005-0505 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29- 120 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) CategoryL BUILDING PERMIT Permit# BP-2005-0505 Project# JS-2005-0662 Est. Cost: $1944.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: BRYAN ALOISI 119772 Lot Size(sq.ft.): 14418.36 Owner: COLEPAUGH ARTHUR E&LAURA J Zoning:URA Applicant: BRYAN ALOISI AT. 70 FOREST GLEN DR Applicant Address: Phone: Insurance: 107 ROCKY HILL RD (413) 549-5141 HADLEYMA01035 ISSUED ON:10126104 0:00:00 TO PERFORM THE FOLLOWING WORK.REBUILD CHIMNEY TO ROOFLINE 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 Sienature: FeeType• Receipt No: Date Paid: Check No: Amount: Building 10/26/04 0:00:00 3985 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo