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29-077 ;_Grify of Warfhanipton r �IlH35At}tliSttf9 DEPARTMENT OF BUILDD0 INSPECTIONS INSPECTOR '212 Main Street • Municipal Building ' Northampton, MA 01060 r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sups: ,isor. 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 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 fegulations. 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 hour), 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 ; } y Cris ) of 'Norf 11allip toil j ` �t iJa RCh nL[tta _ DEPARTMENT OP DUILDD,10 INSPPCTIOI.'S - 212 Main Strcct ' Municipal Duilding Northampton, Mass. 010GO _ w0IUc:R'S C01APENSATION MSURA-NCF AITU)�i�Tl�" I with a pr�,-tcipal place of businessfresidence at: -------- •I TO P0 01660 ( dtY/state/gip) do hereby certify, under the pain and penalties of penury, -1:n ( 6, a-m an employer providing the followinu_ workcr's colnDCnsaoon cove Mge for Ind elnpiovees wor>Jrl on tiiis job: I , It,c, 7 �c Conn.) (POUC%N'L_=_T) O I am a sole proprietor, general contractor or homeowner(c cie one) 2Dd have hired the coon-actors listed below bo have the ',oHo%vIDQ Worker's Ca0oen_sp-t7on pcLicies: (N ZIMC Oi CO:1!7Ci0") (Insuranc CoIno1ny/PobC-{ I I (Name of COatraaor) (Lns-w-nCe Comoanwpobcti, `u-mc:r) (Ex-Dimuon Date) (Name of Connaaor) (lnsutancC Compan)•/PoUq- Nwnb�r) (Ezaim600 Dalc) j - I (Name of Contractor) (Lasuran Comp zny/Policy Numb:r) (Expi a6oa Darr). (nnach-'duioaal�cC,ifncoc[�-w induct_iafonnsEoc Pc-L aias to.11 Dots-ln�) ( ) I am'a sole proprietor and have no one working for me- ( ) I am.a home owner performing all the work myself. NOTE:plea be. t ifi* bo cmplay pcz-L s to do cs•.c.wo r rtpair-ark on[d.-J:_9 of pot mole th-.a Luse fu in u'aeh the bommo o,r cmd,or oa the V-ouac.t+ ox C=�:_Uy ccc=d-nd w be caV11DY-11 the o= • iica Act(GLI1 S2=1(5)} applinDOa by a bomeoQaa fin a tics_or permit rn:y[i&—the iIc�al nav:of ea dro Wockoe,Compom.tion Aat_ i I undcnxnd dva a copy of this ctstccicm my be fcc�nrdnd to Lhe pope tms of Iodu i j Act+ d..&OT,o or 4sti<[.nm fo[the cove-ah-c vriGatioa and that L-iltat to tcau=tovcmcc under socdon 23A of MGL 152 can Ied to the iWOSi =of eiminA pen+ = 000aitis of a floc of up to S I}00.00 and/or i rq riJ'a of up to one y.and ci,i]pmahuo iu tx form a(-Stop Work.Ord,and a fim 0(5100.00 a day Lpi¢A tnc I For dc — use only - i --.—' _ Permit 1-iumtxs ��?y�1�.�-7, i<fap�—_ Lot Signature of Lica>_scr2permitt Datfe j SECTION 8-CONSTRUCTION SERVICES + ' 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: zo `f License Number 1 Address t, Expiration Date Signature Telephone a xa sn xg<--- s ,� sa .9 Meats ere ct. ome mpro remerimbi tra or Not Applicable ❑ Company Name Registration um er —--- __ Address Expiration Date �,F' <i^,�i �y,� <x !J '�' /fit✓ U Telephoney �'f/ SECTION 10-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 buildiZ permit. Signed Affidavit Attached Yes......, No...... ❑ % ; 21, on 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 r SECTION''5--DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition [� ,: Replacement Windows Alteration(s) Roof g ❑ Or Doors C1 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[ Other[0] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet saFw if N 16h ti exls incr oustnc-bomp�ete.the QtlOWtna: 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. f. 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 r l /,t� A—) as Owner of the subject property - dd hereby authorize �=- �'y9 L� 1/5'rlij k/ to art on my be- I n all matters r tive to work authorized by this building permit application. v/ �"/'} "I, <)I-/ G y Signature of Owner Date I, Ll ro A2',XJ a&41 +ln r/Authorized Agent hereby declare that the statements and inforhation 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 Ear/Agent Date ,R a Section 4. ZONING All Informatibli 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:h L: R:! �E '� { Rear Building Height --- —_.4 Bldg.Square Footage % 1 Open Space Footage % (Lot area minus bldg&paved L_J I parking) #of Parking Spaces I j j I Fill: I (volume&Location) I A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued::! { IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW U YES U IF YES: enter Book i Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 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 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 0 , NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. f ,y - City of Nortf a mpton Building Department - 212 Main Street e at k - - --- Room 100 r e as Northampton; MA 01060 e o L poroho 413--587-1240 Fax 413-587-1272 a , 0the1PiC APPLICATiOMTO: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 byace � A _ T7© 4G"0120ov— oe— [� /" 9 �� r ©J Overlay`Dtsfncf SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: T'e9•�, Ta �J -- Name Print) Current Mailing Ad ress: OF Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS-- Item Estimated Cost(Dollars)to be Official Use Only com leted 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) / u U `'% Check Number This Section For Official�Use Onl Building Permit Number. _Date. Issued: Signature: 1 Building Commissionerlinspector of Buildings Date 70 ACREBROOK DR BP-2005-0513 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-077 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2005-0513 Project# JS-2005-0672 Est. Cost: $10087.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: B & R Siding 100465 Lot Size(sg ft.): 20603.88 Owner: O'BRIEN WILLIAM&JUDIANIVE Zoning.URA Applicant: B & R Siding AT. 70 ACREBROOK DR Applicant Address: Phone: Insurance: 781 Bridge Rd (413) 586-4167 Workers Compensation NORTHAMPTON MAO 1060 ISSUED ON:10126104 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL VINYL SIDING 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• Receipt No: Date Paid: Check No: Amount: Building 10/26/04 0:00:00 19586 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo