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29-083 (2) � � fllrlassac{�nsetts iy 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 has/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 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 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 understand the above. (Ho wner/resident's'signature requesting exemption) I will 1 to schedule all required building inspections necessary for the building permit issued to me. Date A�/��(,�,3 Address of work / location ��pr��tr e �2 ai©6d r r (%iN of17l:t1jampfnit _ � 6 fiixsartchn6rtte ' • I __- ^s DEPAJu TMENr OP BUILDING INSPECTIONS �m 212 Main Street ' Municipal builcling Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AYFUMNIT v.,th a principal place of businesslresidence is -?_7_G/ r4tz �arY ? !✓2�t Q!o.2 CIO hereby Ccl—d}:- uln lt" L}le 2) ii1S :?i10 Pcil 1tic`'s of per]tlf�t :Ili!(. ( ) I am an employer providing th-, ffillowlillz compcnsation cove:r: c =or Illy elliploycts working tin this job: (Ins=c:• comp-2ny) (P0' c:NU.nbcr) ---- (ra rir.:Iion Date) ( am a sole prop ieto lltnPrLl c-Dnmc:.cr .�r hor.-Owner lciicle one) and 'gave Erea the contractors l.lsted tbt'loCi 'ti i]0 11-v e th-, `01! .':t; 'ti''Or F:P�S CUL p°IlSc Orl JO!iS'.CS: (,Taimc of Contractor) (Fns �ncc i Iran ;r;Policf NI rnLYr) r xi) r-,--L cr Datcl a q/P ali o�S�r. Cam�y l/ 3� y�/� amt of Cont?<.c,,,or) Daic) —.. (Nam of Coatmctor ---- - -, - =.x, �c- Date � ) ,Insa .ncti Com a�;�;i�r'oVic; Nu�i txr) .- ) (Name of Contnctcr) —- (Iasi rand Color�'1}' PolicY Nu.mbwr) (F;zri-:tior:Date) ( 1 c1IT1 cl Ule 1?I"Ul?I1C tC?i r.:11 hElvc Im one ..'UFk m,—, tOi :Ile. ( j Hill <1 1:011Te OVlI1C. i)CriC'IT11I�^ �(1 iL J,_ .., b 1 NOTE:picric to aw:z:t li:a:•wL-; c l t;co«im t+ �r..np! ,>.- ; n:: <__.�nc�ar:._r�m ca:c,>au—6-_•.. not uxYC t1L n tlum uuis i.^,tc{ dt��c br.» azr ra: or oc;L` �:;;:s zp-•rtcr r1 ihcr o L n-<�C,sallY ccr.:'::::':c cZ'•ploycz u_ur the tw:; _tr^t•::_i-n i+c:((31.152-:�s 1(5)).ak:,•ii^.;ia;by a hnxmco,t->-r for:G ex cc Icgal etatuc of rx o=Vloy-r under tba Wcvlcle Coar>r,tion Act_ I uz-�dctta d thil a copy of this ctatc.'s1 cuy bo faw,vciod to v»IYSiorVnrn:of Itv,}us!ricl Aro&. *Y Off",c of for tlx oovc ase vaif Ilion and that Eilum to a r:co%,-r_i�o ua3:<"iM 25A cd?.{GI.152 can Ir d to the i:npositio;n ct cr i._1 pa:sl:::s oomuting of a fur_of up to 5 1.500.00 an&or ir:pri:x: :1 of::p to cr.:}- aM civil r>m.1 is in t f— cf a S!r,,`crri'.n a and fin--or:;I 00.w a clay t�r_inst tat. .- rcKdr�%uVZYStaI uie oat}' Pcrinit rltlmtx r I r t_CT�OIV4g zCONSTRUCTIQN SERVICES 77q 8 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone Qe , ene me ,m Ve eh—on�trafcto= Not Applicable ❑ Company Name Registration Number -2.7 esz- tY l61)yO6 33 Address Expiration Date �QS �'rm��ZSl1 /7'�R 0!d.Z"7 Telephone 7z �l ®y SECTIO °0�'WORKERS, COMPENSATION INSURANCE=AFFIDAVIT(M G,.L ,.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 acecptable 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 �ri� i ��SGT�ON `� ` R P �t`Ol+i(3�`�'I��ROPOSED<ilY RK check�.all a I+cable �w`r�k ':is Doors New House ❑ Addition ❑ R Re lacement doves Alte ration(s) ❑ Roofing ❑ Or Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: E'ioIuC e (Cron% Qck ,Door'5 Alteration of existing bedroom Yes�o Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll❑• Sheet 0 6a: ,. __ear O° o., a dititon toe istingho 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. Mascheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodpiain 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 'SEGO llif[ Ei T#]pR1ZAT10N TO BE COMPLETED WHE OYVN rSEN 0 �(iONTRACTOR APPLIES FOR BUILDING PER I, US.S r Qv/7— as Owner of the subject property hereby authorize S7`cg4/PSO y Q4 4- to ac; on my behalf, in all matters relay e to work authorized by this building permit application. X, !/ o Signature of 0 Date 1, 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 r Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This colunnn to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW ✓ YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 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 NO V IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property?YES No IF YES, describe size, type and location: ' I a City of Northampton A Building Department 212 Main Street Room 100 Northampton, MA 01060 : phone 413-587-1240 Fax 413-587-1272 _ w APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ,SECTION 1 SITE INFORMATION: Th sectriopp,40 completed isty oflst3e 1.1 Properly Address: q��� �S Ago Lc e In Q Q�a�i� �n� ��� �� , r ►er����c SECTION 2-PROPERTY OWNERSHIPJAUTHORIZED AGENT 2.1 Owner of Record: ll?4� Du ss ea id r / .,acre &vnli Name(Print) Current Mailing Address: ! cr e,n c, e.. zn 4 ^14 b ALTelephone Signature to 6 2.2 Auth rized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-E'STIMpTfD'CONSTRUCTION-'COSTS Item Estimated Cost(Dollars)to be ,x Of l ciaWse Only completed by ermit applicant 1. Buile�/ccc,E rcJa �C�;' o -(a)Bwling Perrrat-Fee Doc.. S 2. Electrical =((t) EsOmated�Total Cost-:of 'Construction;from"* 6 3. Plumbing Building°Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total = (1 + 2+ 3 -Chet'k- umber This Section-'For Official wWe�Oiel Building Permit Number: Date issued: Signature: Building,Commissioner/Inspector of Buildings Date 21 ACREBROOK DR BP-2004-0627 Gls#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-083 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2004-0627 Project# IS-2004-0878 Est. Cost: $300.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sa.ft.): 14984.64 Owner: DUSSEAULT ROBERT EDWARD& Zoning.URA Applicant: DUSSEAULT ROBERT EDWARD & AT. 21 ACREBROOK DR Applicant Address: Phone: Insurance: 21 ACREBROOK DR FLORENCEMA01062 ISSUED ON:11119103 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT DOORS 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 11/19/03 0:00:00 6649 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo