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29-021 (4) TD _lice, b X en Tacks L # Z-A T YY tAe r\ OgSt1AMp�O Z �I 835AC}jliSttt3 of Warthamptan r DEPARTMENT OF BUILDI7,,TG INSPECTIONS /= '2112 Main Street • Municipll Building INSPECTOR Northampton,MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to act as his/her construction sups:,' 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 fame y 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 Vuil mg department for the City oTNorthampton wants-arty 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 r',egulations. 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 L 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-tome _.. Date Address of work location r � w - I , ¢TtIJV-f P�. J.. O `E 6*f-�3 of {cr�fl�ailt}�foi1 _ �, f �Zc31 AChasclfe' — o DEPARTMEI-T OP BUILD1)�G INSPPCT101"S I _ j 212 Alain Strcct Municipai Building i Northampton, Mass- 01060 t WOR1 ERIS CONIOENSATTO-N AIT�� I --- with a pMi cipal place of businessfresidencc at: -- - l�0 I<0g)g 1)R'. no/Vijc� (p;one') `�I"� - o f j ��sl (sum t/ci try Jsia.tc.Ia P) do hereby cerr--, under tic.pains and penalties of perjury, hat ( } I am an employer providing the following %voriccr's cotnocnsad0n cove arc for lny etnplovecs working on diis job: (Insar-anc Com=zy) (PoLiic:?�,=ter) -- (r:pirrior. Dzl-.) O I am a sole proprietor, general coo=czor or homeow-cer(c cie one) and have hired j the cone actors bsted below rgbo have the `ollol"'* worker's coc:oen_saaon pokles: i Of Contmc.or) (Insumnc. Coinpan)-Pl ouct Num=c:) (ri:)i,ata0n D.11c — (N:..me of CODU-21 t-0 (LrI5-lMZC: aMDaati'IT01Cv \uncrr) FaPindon Dale) (Name of Cona-actor) ansurdnc:Com - Tun}-/PoUcy Num)x:t) (Eepiraen Datc) (Name of Contractor) U=u=cc CompanyRoUcy Numbcf) 'E. it�6on Date). (nr� dl�ocil bra,tacccv_ti-to ax?u�iafortnaaoo pctaia as to.I1 i am a sale proprietor and have no one working for me. ( ) I am:a home owner performing all the Nvork myself. NOTE:p_l-. lx cveyt ttixz wbij,bcm wvc z..to c=p1ay pa C=—= c c rcp-x�Mrk on.d%,-U:^;:of 6Dt IaOft tfL:S1 t1Oe l^SYs La%z-h C the bOtt100wDG raid. oc oa tb.c Q'oundy,7pu�nc,eo,ooc C=c-cny a-=.d--cd io be t atPlo7�z und.=the..ui ct c==;> +:oa Att(GUI 323=1(5)).=-ppUca6cro vy a bommo>va rc a bcz-.=or pcmir rr_y cv-v m the lcP1 cL==orna c`pioyr mod,dro ulO k e'compoa,,,Z;o Ac< I I uadc*iand dza a copy or t1w mtaaca may be forte carded to c4.Dcpa,rmr�arinbcuic!AoodcWJ far th. ���;bt�itclioa stud tint C iliac to ca�ut oovaneo mdc soc�oa 23 A of MOL 13-1 caa tnd to the L=Pcz ioa of cimiad pcM'I of a Gx of up to S 1}00.00 artdfor or up to ooc y.-�end c%il p=AI-ua is the form of.Stop work Ord,-- aid a f=of S 100-00 1 d_y a,- For dq.r^f•�u.c only __—._._� / }?CfIIIJI Nt1IDtJC: _ - 1` n" Si Ana iurt t c� clPc tzni tic TJ3�e l SECTION 8'-CONSTRUCTION SERVICES 8.1 Licensed Construction Suyeervisor: Not Applicable ❑ Name of License Holder: to License Number Addres Expiration Date t I r S d,0o Sign Telephone 9 Re'Tslere1efin rawemeontrat<t Not Applicable ❑ Company Name Registration um er Address Expiration Date Telephone SECTION 1"0-WORKERS'COMPENSATION1hISURANCE iaFEIDi41ftT"(M:G 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.......�r7 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 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 K r.. SECTION 5-DESCRIPTION OF PROPOSED WORK{check alr:applicabre) New House ❑ Addition ❑:. Replacement Windows Alteration(s) Roofing [� Or Doors Accessory Bldg. ❑ Demolition New Signs [0] Decks [p Siding",] Other[o] Brief Description of Proposed Work: S3U � L`�_ �J_l C01,AAN{ `I Alteration of existing bedroom Yes _No Adding new bedroom Yes X No Attached Narrative Renovating unfinished basement Ws No Plans Attached Roll -Sheet 6a.GfCeW ]70E7sean= rdrt�afcxrstt otsrn ..corn tetr� tr fQUrr i 1�.�f hi dir nn'fine Family Two Familv Other b Number of rooms in each family unit: Number of Bathrooms Is there a garage attached? i . Proposed Square footage of new construction. Dimensions Number of stories? Method of heating? Fireplaces or Woodstoves Number of each 1. nergy Conservation Compliance. Masscheck Energy Compliance form attached? Ty e of construction i. Is c struction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain - Yes No j. Dept 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 Ta-OWNER AUTHORIZATION-TO'BE COMPLETED WHEN OWNERS-AGENTARCONTRAGTORAPPLIES FOR.BUICDIhIG PERMIT 1 1 f y G i/ Q as Owner of the subject property hereby authorize I q to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Ownery Date Jim— I, _TAB PeN S rJ`� __ 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 ame Signature 0 ne Agent Date Section 4. ZONING All Informatibh 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 L. � R: Rear Building Height Bldg. Square Footage _ % �— -� I ; Open Space Footage % JJ : (Lot area minus bldg&paved �- parking) 3 #of Parking Spaces Fill: (volume I&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? N0 C) DONT KNOW YES 0 IF YES, date issued:! 1 IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW YES Q IF YES: enter Book Page! and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW JQ YES 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 IF YES, describe size, type and location: j D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO 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 i IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of No arnpton s= '01B it i partment roc ' ayR r ain Street Room 100 r eti ya��f� � - orthampton; MA 01060 �P � phone 413-587-1240 Fax 413-587-1272 PtvtdS fang � ¢� . APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION A,-SITE-'INFORMATION This section,to be completed by office 1.1 Property Address: 17 14, QK©� / Maps dot Unit 0106f Zone O�rerfay�D�tncf ,2, w Efn S District SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: G 1s4- 0 t 7 IA I K cc I Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: cT A n 13 Name(Print) CurrenT Mailing Address: Signat Telephone SECTION 3.-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building cD (a)Building Permit Fee 2. Electrical T� ( (b)Estimated Total Cost of Z LIP() Construction from B 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 Date; Building Permit Number. Issued`: Signature: i Building Commissioner/Inspector of Buildings Date File#BP-2006-0437 APPLICANT/CONTACT PERSON James Finnlv�I ADDRESS/PHONE 21 Henry Street NORTHAMPTON PROPERTY LOCATION 17 HICKORY DR MAP 29 PARCEL 021 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Constructio Sunroom addition at rear of house STRIP&PL REAR ROOF New Construction Non Structural interior renovations Addition to Existing Accesso1y Structure Building Plans Included• Owner/Statement or License CS 088014 3 sets of Plans/Plot Plan THE FPCLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF94MATION PRESENTED: 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 Cgr ssion Signature of Building Official 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.