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35-047 (2)
��HAMPT Crity of Nazthaurptaln f D _ $:. � +,1i'rlassRChusetts - r DEPARTMENT OF BUILDD\TG INSPECTIONS INSPECTOR "212 Main Street • Municipll Building North=pton,MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as 1;1s/her construction sup,:: .-'sgr. The state defines "Homeowner" as, "Person(s) who owns a parcel on which he/she resides or intends to be, a one or two famly--- 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 �0 °FE (rii Pf 'fact tl1arlt}itoil _ ,4 E -el aoaltchnrrIts _ v DEPARTk4ENT OP BUILDrI\'G INSPEC JONS 212 Alain Strcct Municipal Building .a Northampton, Mass. 010GO WORICCRIS CGIAP ;NSATION GNSUR -N CE AFT DAVIT" I'al �l-(_ - (liccu;.xlncrmittcc) v,r1th a plb,-lcipal place of businessfresidence at: -------- -- 70 /Z;2 % �2g G,u' S%. (phone..';) (sIIr� ticityls=c./ap) do hereby certify, under tbe.pairs and penalties of perjury, hai ( ) I am an employer providing the following'worlcet's colnocnsation cove age for Inv etnplovices wor ang on thus job. (LanLnMc Conroy) (Polio:Numbcr) -_ (1=:-piruor,Dz1_) ( ) I am a sole proprietor, general contractor w onactor or homeoner (circle oee) and have hired e cocuactgrs listed below wbo have the folio,.ving workers conp°nsauion policies: An�=�t,� J � ©.>*ZrvlFncfGc�o� ©l O C. (i+nmc Oi CO^!?Ci0") (Ins-urance Cornpan}-RGUCi NtuII1Ct:) D11C) (Name-of Contraaor) Gn -ar-ancz ComoanvlPollCv Nuncrr) (L»irT-bon Daft) i (N:me of Con!_t-aao,) (Insurance Comp= /Policy- Numbu) (Expirzrien Date) (Name of Contractor) (L asumncz- Compury/PaLcy Nunab_f) (Expi z6oa Darr) . I {nIIaCSl ad'ta-Lxa1 t�cc,ifacccur,-w a�cu�iafoc�'ioo pertaiain6 w.11 oocrs-_con} O I am a sole proprietor and have no one working for me. O I am.a home owner performing all the work myself. iNOTE.plese be aw-.ut Cfict w-1 le bcmrAV VCn u$o cwp Icy pa=w w -a oo C rear work ua a d••c11--g of ant Mott 11—L• .tats in--bleb the oc oo the V c6 zp�tbe-e to be -avlar--uac!c the--Oz r`t x= uoa Aa(GL'152=l(5)�:ppii=Ecc by a boazzoQac f=c lice-of permit y EL-': Ic-91 ct--ue Of en¢:Ployec coder du Woh ,Compom..tioa Ace- [tad the i oopy of thin car-m.=m.y pa foc--xw•dod to tbo pcgarto�r of Iv�+xricl Ac &..Ey Of>;w or L--' o for th. covcrlSt vciGeaioa cad Ox-u L-iltae to Lcoirt`eoverasc under sec ljoa 25 A of MGL 152 as 1¢d to the i-POlid0a of mmiaa!pcasliica 000si-c g of a fiat of up to S 1 500.00 andfor o f up w ooc yr_r and aril pasahum is(b,room or a Stop` 06o Ord=Lad a fim of S 100.00 L day Lea Mc Far dG>zrtasl-st u+c only - �` - per$it NuIDtxr -i ap" Lot Signacun of Licx=risczJrcrniucc Ua -J SECTION 8-CONSTRUCTION SERVICES r 8.1 Licensed Construction Supervisor: Not Applicable 0 Name of License Holder: //% 7 T,, License Number V Address Expiration Date Signature Telephone S'Fteaisfeie" kfoiainaaiveineiiCoiit aka' � v Not Applicable ❑ i A 1 q z9 t A a 6F= Company Name Registration Num er Address Expiration Date G/V,6 Telephone SECTION 10 WORKERS'COMPENSATION INSURANCE`AFEIDAYIT G (M. L.c..452,§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...... ❑ ei The current exemption for"homeowners"was extended to include Owner-occupied Dwellings 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 Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature r i t.• 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[C�, Other[0] Brief Description of Proposed op Work: '57A�Q f _e Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet tii 4fNe Th6bt arid&i� c ilctiaWid eAinh ta- 6 irtg�ca ptet fh "# four i> g: 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 fOR BUILDING.PERMIT C i9 as Owner of the subject property hereby authorizefj to act on my half, in all matters rel ive tow k uthorized 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 Side L:! R:1 L: R ' 3 � Rear Building Height — -~ Bldg.Square Footage i % r Open Space Footage _ E-^ % �--- (Lot area minus bldg&paved 3 -- parking) #of Parking Spaces Fill: (volume&Location) ' A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issue& i IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW 0 YES I IF YES: enter Book Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0 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 0 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 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 Q ,. NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. w City of Nortf ampton ' Building Department . e 212 Main Street � ,_ Room 1,,00 e � Northampton; MA 01060 P phone 413-587-1240 Fax 413-587-1272 Plow APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1.-SITE INFORMATION This. ect1drt to be com feted b office 1.1 Property Address: P Y C"" � Zone . .� OveriayDrstncf m Sf D�strrct C�Dtr�ct s SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: •,� , ALI Name( ) 'L /) Current Mailing Addres Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Urr�U. 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 This Section For Official Use Only Building Permit dumber. -Date-:. Issued: Signature: , Building Commissioner/inspector of Buildings Date w 978 RYAN RD BP-2005-1120 G1S#: COMMONWEALTH OF MASSACHUSETTS Map:Block:35 -047 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2005-1120 Project# IS-2005-1514 Est. Cost: $5000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Edward T Corbett 119488 Lot Size(sq. ft.): 15681.60 Owner: PRYBYLO ALAN R& Zoning: SR Applicant: Edward T Corbett AT: 978 RYAN RD Applicant Address: Phone: Insurance: 1 TERRACE VIEW (413) 584-2546 EASTHAMPTON MAO 1027 ISSUED ON.5111105 0:00:00 TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE 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 Occupangy Occupancy Signature: FeeType• Date Paid: Amount: Building 5/11/05 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo