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M z X— .. HOOK Co M v n PEDELABORDE Residence
C-
M = � ; Design & Build Associates
N �_ 14 Gilrain Terrace
M m Z 51 Ridgewood Ter,Easthampton,MA 01027
Z Florence, MA 01062 N N phone/fax 413-529-7140
n °o °o hookdesignbuild @gmail.com
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ENERGY CONSERVATION APPLICATION FORM FOR
LOW-RISE RESIDENTIAL NEW CONSTRUCTION and ADDITIONS
780 CUR Appendix J
Applicant Name: $e'h *Dk- Site Address: rat'I T-er
Applicant Address: 5) P444 1 16�' City/Town: 1=to M l'1 u—
E"44 aadA+ in PVI-F7F Use Group:
D(0Z"7 Date of Application: Q,Yz4A 2.00
Applicant Phone: 413 -57--4 --I ID Applicant Signature:
Compliance Path(check one):
❑ Prescriptive Package(Limited to 1-or 2-family wood frame buildings heated with fossil fuels only)
Package(A through KK from Table J5.2.lb): Heating Degree Days(HDD„)from Table J5.2.l a:
(For items d.through i.,fill in all values that apply from Table J5.2.1b:)
a. Gross Wall Area sq.ft f. Wall R-value R-
b. Glazing Area` sq.ft. g. Floor R-value R-
c. Glazing%(1 00 x b_a) % h. Basement wall R-
d. Glazing U-value U- i. Slab Perimeter R-
e. Ceiling R value R- j. Heating AFUE
❑ Component Performance: "Manual Trade-Off'(Limited to wood or metal framed buildings only)
Climate Zone(from Figure J6.2.2) ❑ Zone 12 ❑ Zone 13 ❑ Zone 14
Attach Trade-Off Worksheet from Appendix J, [and RVAC Trade-Off Worksheet,if applicable]
❑ "check Software
Attach Compliance Report and Inspection Checklist printouts
❑ Home Energy Rating System Evaluation
Attach Home Energy Rating Certificate(HERS rating score must be 83 or higher)
❑ Systems Analysis OR ❑ Renewable Energy Sources
Attach Mass Registered Architect or Engineer Analysis
_ ALTERNATIVE FOR ADDITIONS ONLY:
a. Gross Wall+Ceiling Area!6 = sqA. b. Glazing Area` 114.1Sj sq.ft. c. Glazing%(Io0 x b=a) A 1
❑ ADDITION with Glazing% (c.)up to 40%may use 780 CMR Table J1.1.2.3.1 below:
MAXIMUM U-value MINIMUM R-Values
Fenestrations Ceilin , Wall Floor Basement Wall Slab Perimeter,Depth
0.39, R-37 I R-13 R-19 R-10 R-10,4 ft
1 Glazing Area may be either Rough Opening or Unit dimensions.
2 Based onNFRC listing. Applies either to every unit,or to area-weighted average of all units.
3 R-30 ceiling insulation maybe used in place of R-37 if the insulation achieves the full R-value over the entire ceiling area
(i.e.-not compressed over exterior walls,and including any access openings.)
❑ "SUNROOM”addition(greater than 40% glazing-to-wall and ceiling gross area)
Attach"Consumer Information Form"from 780 CMR Appendix B.
Official's Name: Official's Signature:
Application Approved ❑ Denied ❑ Date of Approval/Denial:
Reason(s)for Denial: (provide additional details as needed on back side)
r .
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�z of 'Narf4a»lptan z
� �1��sR�n�tg�tts
" DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building '
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as its/her construction sup,,-., •- sor. The state defines "Homeowner" as, "P erson(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 hued 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
•
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of In vestigations
a 600 fVashington Street
Boston,MA 02111
www.mass.gov/dia
-Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): }-f(�C7 k_ ��SIPY1 A i ld Irv) As6QG110_10S
Address: P,*dAj L,J,00 d T.e," ct
City/State/Zip: 01 OZ Phone.#: -`+1 JS -! -:Z 1 /+D
Are you an employer?Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. ❑ I am a general contractor and I
�loyees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.02 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers'
insurance.$ 9. El Building addition
co
[No workers' comp.insurance mP•
required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption'per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp_policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage,as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1;500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby certifQy,under the pains and penalties of perjury that the information provided above is true nan_and correct
Signature: �i�`` x�a �, 2 Date: WUAI- y1 C2:7
Phone#: l �aoZ�1
Official use only. Do not write in this area,to be completed by city or town offcciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
•
,
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: (,��y�� r/ Not Applicable 0
Name of License Holder: E U ZAO—&l t 1 ply Cis o-79
b I
License Number
5 fi-(�'YZt 54i)a w-o4n 0102:7 (a 11 f2( 0-4
Address Expiration Date
Signature Telephone
9.Re4istere i"Horne lrri`pravement o,n6a, Not Applicable ❑
IA-vcK-- De,51e,n 14 5q5&
Company Name Registration Number
51LA�ve d ` —� 0107-` 3[1 y to!
Address Expiration Date
Telephone 5-2A-:214-0
SECTION 10-WORKERS'COMPENSATION.INSURANCEAFFIDAVIT(MAL.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...... ❑
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 Gable 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check°all'-applicable
)
New House ❑ Addition Replacement Windows Alteration(s) Roofing
Or Doors
�—y
Accessory Bldg. ❑ Demolition E New Signs [O] Decks [1;2r Siding[0] Other[E:j
Brief Descr tion of Pf oposed � �` 05 r
Work: da L'�N'���?.�,064 4D bac ¢ viy,� m�1�1 In/�.ti4-G�'1 1�L���/�..' rVi. 2��al&I43 -vJ ink e�
---� 1 +
Alteration of existing bedroom Yes_ No Adding new bedroom Yes V__No
Attached Narrative Renovating unfinished basement Yes L,--' No
Plans Attached Roll -Sheet
6621f,New house:and,_ d"ctitior>.ta.existing: Q�is na coi p efe the fii[aiiirii g:
a.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? 't!S
Z f y r !I
d. Proposed Square footage of new construction. _Dimensions 5 0
e. Number of stories? 'I 1I�
f. Method of heating? Lt / Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. V Masscheck Energy Compliance form attached?
h. Type of construction_ Vr-C
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 `7T 1
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,AP PLIESlk)R BUILDING PERMIT
ALA-I 1(4 V1 -r 1 It �' as Owner of the subject
property
hereby authorize 1 ' A VN
a my b h If,r ly matters( lative to work a o ' ed by this building permit application.
j SI �
gnature o O er Da
r
1 �� �`e 7 as Owner/Authorized
Agent hereby declare that the statem is and information on Vie foregoing application are trub and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Ow'ner/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 Frnnt
Rear
Building Height
Bldg. Square Footage TAW 3,2
Open Sna--c Foot %
A. Has a Special Perm it/Varia nce/Fi nd i ever been issued for/on the site?
NO �^�� VV� DON7KNO �u� YES v���
�
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO K ) DOm'| xmum/ ,Ex
��
IF YES:� enter Book Page and/or Document#' !
�� ��
B. Does the site contain a brook, body ofm/oterorwetlands? NO K�� DONTKNOVV �~� YES «��
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tmbeobtained �~� Obtained � �-� Date
x_� x�� ' '
C. Dn any signs exist on the property? YES NO
0 v��
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 6istudb(clearing,grading on.or filling)over 1 acre oris it part ofo common plan
that will disturb over 1 acre? YES ��K l NO &�
��
IF YES,then a Northampton Storm Water Management,Permit from the DPW is required.
.4-o 6t-- ` r dw
Depertmen�us�onx �
City of Northampton Stafs of Peim�t
Building Department urb C�ftDtyeva 'errn► r
212 Main Street Se VG'r trc P�fa6��t� 2
Room 100 WafetellAvarla6tl,tyt ,
Northampton, MA 01060 Two Sefs of St ct�zraGlans ' ' "
phone 41 -587=1240 Fax 413-587-1272 PIat�Stte Plans
M.
OtherSpectfy r -�, ' r
a _
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.INFORMATION
1.1 Property Address:
This section to be completed by office
�'1'Irc'til n Te v'ru. G(, Map tot Unit
OverlayWstdct
wrElm St.:;Distnct • y� � aCH Distnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ba i1 -re It bC irc1• I ,,, �S t'
u, .t •,-V i I�G���trGi 1v1 -y'- FI v lyoC.c ,l'111 1 1
Namt' Print) j Current Mailing dr ss:
a
y 5-57
f � Telephone
Signature.
2.2 Authorized Agent:
4-6�
Name(Print) NJ Current Mailing Addr s: /0-;0-7
Signature Telephone
SECTION 3-ESTIMATED.:CONSTRUGTION`COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building.Permit`Fee
2. Electrical (bj Estimated Total Cost of
Construction from. 6
3. Plumbing O l0 Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) O O o Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
or
File#BP-2007-0863
APPLICANT/CONTACT PERSON ELIZABETH HOOK
ADDRESS/PHONE 51 RIDGEWOOD TERR EASTHAMPTON (413)529-2189
PROPERTY LOCATION 14 GILRAIN TE
MAP 29 PARCEL 052 001 ZONE URA/ Vj�
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid off
T_ypeof Construction:_CONSTRUCT REAR DECK,ENCLOSE BREEZEWAY/ADDITION INTO
MUDROOM/DINING AREA
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/Statement or License 079641
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN$ORMATION PRESENTED:
V Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance* _
Received&Recorded at Registry of Deeds Proof Enclosed _
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission
Signature of Building 2Zial Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
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14 GILRAIN TERR BP-2007-0863
GIB#: COMMONWEALTH OF MASSACHUSETTS
M Wk.29'-052 CITY OF NORTHAMPTON
Lot:X01 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Pencnit:` Buj na DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c-142A)
Category: - BUILDING PERMIT
Permit# BP-2007-0863
Pro gg# JS-2007001422
Est.Cost:$b8000.{10
Fee:Ss5.c PERMISSION IS HEREBY GRANTED TO:
Const.Class Contractor: License:
Use Croup: ELIZABETH HOOK 079641
Lot Sizetsq'.ft.):.9626.76 Owner: PEDELaORDE DANIELLE&HILLARY GOLLIS
Zoning: - _'.,_. Applicant: ELIZABETH HOOK
AT: 14 GILRAIN TERR
Applicant Address: Phone: Insurance:
51 RIDGEWOOD TERR (413) 529-2189
EASTHAMPTONMA01027 ISSUED ON.3/27/2007 0.00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT REAR DECK,ENCLOSE
BREEZEWAY/ADDITION INTO MUDROOM/DINING AREA
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter: doe., S Bh S--1-0 7
Footings:
Rough: Rough:�/� House# Foundation:Q� .a - O7
1� Driveway Final: -Aem
Final:N.si� Final: 0-7 •
�: Rough Frame: f( P /� (N S Ro
F- -6CT04 GV, d�� qq 9111°-7eom 15
Gas: Fire Depa,rrtment Fireplace/Chimney:
Rough:',Y "' il: Insulatiouj:5
Final:
Final: g"'Q7 Smoke• b 6 I I ? 41
THIS PERMIT MAY BE REVOKED BY THE C TY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL IONS
oe
Certificate of Occu anc Si nature:
FeeType: Date Paid: Amount:
Building 3/27/2007 0:00:00 $55.001120
212 Main Street,Phone(41'3)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo