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29-194 $ � �Xrla3axcf�useffs DEPARTMENT OF BUILDIN G INSPECTIONS INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCNM 1083.4 to act as h-is/her construction sup,:: .-7sor. Tlie 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 W inspect work atvarious--stages, which include_foundationl-fv-o-tings (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 �(ltnl•rpT O O R� U�3.a ?E v If t7f �\Tc fljallipfoil Q � �Z a3snrilnsrl(a' - !� © OEPARTNIE14T OP BUIL.DII,,,C 1NSPECTIOIJS 212 Main Street hfunicipal Dudd;ne Northampton, Afass. 01060 WORICER'S CON/EPENSATION •»SURA-NCF AI=AVI-j' I, (li c>`nsxJperm�ttcc) \,,Ilth a pi�,-Icipal place of businesslresidence at: — {phoney') (surer(/ci ty/statcra p) do hereby certif).-, under dic.pa_i is and penalties of pcg'ury, h:i ( } I am an employer providing the followine workcr s cotnocnsabo, cove S.c for Iny elnplovees worUng on this job: (POEC-" Numbcr) -- ( :pir`tion Da .) ( } I am a sole proprietor, general cootractor or homeowner (ci:cie one) 2-od have hirea the Conn actors listen below wbo have the folio v* 9 worker's corn°rLt2aon po!!cies: -- (Name of Cooczctor) (Lns,.u-ancic ComDaa)'/Polim, \tic^r) (Ex-Ex Date) (Name of Coaaac-lo;) (Insurance. Compaoy[Polio- Number) (Exairtioo Date) (N2me of CAntracxor) (Insurance Company/Policy Number) (Expi,,600 Date). (atI�Gf]��ocxl cSca.if nct�csa�-to mclu�iaCortn.7oa pcta.iaias to all mom-r-0:3) - i { ) I am a sole proprietor and bave no one wort ng for me. I am-a home owner performi.ag all the work myself. NOTE:plc be conic it-.M{ o 6CmAwvCT]Ktio¢ IQy Pcsom W do Cr rryau�orz oo a d.,<I -i:of aot mcce th`o tlz w L--Ws is«$ieb the bornoowac raid=or oa the Qotta6 zgpurt<a tbee e.-e ax�^�..:_!ky oc,=.d=cj to be citployc-3 I, c Ibc v aSct;C=PC-•- .Act(GLI S2_=I(5)�z4VLia6oa by n bommava(cr c Vic=_cc p--snit n_y c«dcoc c trc Ic-P!It-=of en crPloyx under dto Wortoe,Comp.omaL Act• 1 t;adcrtapd dhd a aopy oC this my bo r c--ddd to the Dcputnxrsf of In�sriJ Accidenty off—or 4aurz000 for th. coves-zb-c rciraziw nad lh:t L-iltac to ao3irc`covcsasc trader sxt�oa 2 S A of ht4L 152 cza Icd to Ibc�zxxa2ioa oC c-iminal pea�11i= ooasis.iu�oC a rise of t�b S 1500.00 arld/Or orup to ooc yr_r cod aril pm.tia in tic(orm o(a Stop Word Or'de and a run oCSI00.W L day Lpjn.A me Foe de-0u'em=s1 u.e only - �� permLt Number Lot StparttunofLi c _ '�J3�e F SECTION 8-CONSTRUCTION-SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone SaReaistered;IioinetilmpcoverriecitoiitaCfor; �, Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 1;0-WORKERS'COMPENSATION INSURANCEAFFIDAVIT(M:G L_c..152,.§,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...... ❑ INKS 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:Person4s}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 Stat f Massach etts General Laws Annotated. t Homeowner Signature SECTION-5--DESCRIPTION OF PROPOSED WORK(check all,applicable) New House Addition [] Replacement Windows Alteration(s) ❑ Roofing Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [r] Siding[o] Other(0] rief Descri do f Proposed Work: p ,)f7,/j�14Jt° OVI-1' ��E�l� /-/t�•C�[ 1a`�G _ Alteration of existing bedroom Yes No Adding new bedroom Yes _ No Attached Narrative Renovating unfinished basement Yes _No Plans Attached Roll -Sheet spa- IfNei�horlse artd#`orc[� loer �:exsil,naoc>GsrcacalaeifFaurig: 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 'SEGTI0N�.7a•--OWNER;AUTFiQRIZATION TOE BE-EOMP_6E=TEQ-1AftiEN;- OWNERS AGENT.OR:CONTIAGTOR.APPLIES FOR'BUICDING 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 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 Frontage Setbacks Front Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Perm it/Variance/Finding ever been issued for/on the site? �� �� NO �~��/ DON'T KNOW KNO YES x_� IF YES, date issued:! IF YES: Was the permit recorded at the Registry ofDeeds? NO ~-^C ] DO0T K0KNOW YE5 IF YES: ' enter Book Pug and/or Ououment# �� �� B. Does the site contain a brook, body of water or wetlands? NO x_��� DONT KNOW �_/ YES �~/ IF YES, has permit been or need tobo obtained from the Conservation Commission? Needs tobeobtained �~~� Obtained �~� Do�m Issued: x~~/ �~� ' ' C. Do any signs exist on the propart �� ��y? YES \~� NO ^_� IF YES, describe size, type and location: D. Are there any proposed changes tuor additions ofsigns intended for the property? YES 0 NO C) IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre orinit part ofa common plan that will disturb over 1 uona? YES ��� ) NO ���) |F YES,then a Northampton Storm Water Management Permit from the DPW isrequired. r t °City of Northampton wilding Department - 212 Main Street eeaifaFxtl � � F300m 100 el swai a ri � g ''�'/ �^t�tortha'mpton, MA 01060 A0 e'413-587-1240 Fax 413-587-1272 a APPLICATIO TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING r SECTION:1-SITE;INFORMATION: , 1.1 Property Address: This�sectiar:ta-b completed by office ' EfAl t F Ocrerfavgrstcic# ErmrSt Oistrcct CB�f]istrict SECTION'Z'-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner wner of Record: � />/�// e� /1� / O�Lt L 7� d�i�t/r�/ �i /'�c'1�^F!/I✓E� Name(Print) Current Mailing Address: 16 � � Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION-3.-ESTIMAT.ED CONSTRUCTION"COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by perm it applicant 1. Building (a)Building Permit Fee 1,5-ao, 4'Z9 2. Electrical (bj.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: Building Commissioner/Inspector of Buildings Date 46 OVERLOOK DR BP-2007-0405 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29- 194 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2007-0405 Project# JS-2007-000596 Est.Cost: $500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 15986.52 Owner: HENDERSON WILLIAM A JR&JANE Zoning:URA Applicant: HENDERSON WILLIAM A JR & JANE AT. 46 OVERLOOK DR Applicant Address: Phone: Insurance: 46 OVERLOOK DR FLORENCEMA01062 ISSUED ON.1011112006 0:00:00 TO PERFORM THE FOLLOWING WORK.-SHINGLE FRONT HALF ROOF OVER 1 LAYER 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 10/11/2006 0:00:00 $25.006885 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo