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35-219 (2) I , i I i .j i a y •- d fj fA n . - aA O¢ TO (rzty of Nazt4a mptan z $ � �lassacl�usetfs cti 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 his/her construction super.i°or. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two fancily 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, whicit+•'include foundation/footings (before backfill), sonotube holes (before your), 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 1, 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 Gib fif N1artilaillp f oll 6 jil a 3 S Rdl ITS C(t5 m DEPARTMENT OI' £UILDDJ G INSPECTIONS 212 Main Street ' Municipal )3uil(11119 Northampton, Mass. 01060 WORKER'S COMPENSATION INSURANCE AFFDDANT (Ilccns_�'ccrmiltc^} _ ""Ith a principal place of businesslr :;e�nc �street/� p) � do hereby certify. unr;.r 1110, pr.ns and penaltic_. of or,rjtlry, that. I am an employer providirl- the :o1lo'.vint v"ol-t:cr's collipCns�uon COVCr2 ,C i0r 'lly employees working on this job: v !rte' we,kG•�,o - 6 oe f°dL7e/Loes. ..a,£�M ape . �W�3��r-L lZ- f/ (Lnssrancz: Company) t:euc;N ntxr) (`rte pir:d-on Date) ( I atii a sole prop ietor, .Teneri c:�n � t]omeo.��er (c ele one) and ha,e hired t.lie COI1t7wtOrS listed t)C10v-i'i'i]0 1"71, `OHr PFS 001-11)en-1Z 0 (Z`amc of 1-Orltr3ctor) (Lnsumnc CCI ?;iiiPGllCf Nlllnbci) ?'' . .GC' Datc) (Name of Contractor) -- (7.r-iSUM-nce COIIl:D,!-:!y Po!1Cy Number; (E? raiion, Date) (Name of Contractor) (IIiSIC311C^ CO i^a 'Gl;c NUII]l 'C Date) (Name of Contmctor) — JoEunauc- ComI-=,,,/Polio Numl;Lr) (_Exr;!-::ior Date) O i <Lll a sole proprie,,ol i::II:i hay+';, no ollL '. ;1,' for :ne. cr:cPai; not zxYC -1ployv-z u-z,--r the tvcclace: ^n r.((rL 5 ~ _�;x-.-:_� 12.i-•;(51;.-�.;:,a::c:;.,y s hnt•ico«-mcr:`cr e legal etatuc of rn aMploya un(:er!hn Wockc,la Co t;ur .lion .cL i th+t a cmy of!Ls nuy ho fcK Ivcl�l to tln(Yt artz ccL of In6u:riJ- Ax�iLatff'efri v of for tlx covera&c vc iEC:Iioc and that fiiltuc to en !e Co",r C u1:3:sc"ion 25A of MC-L,152 can Ic_ii to thx im;vcsitio t ofr;i; 1 pail:... co—fisting of a fur_ofup to S 1-SC 00 of t:P to C-)-,zr civil xrultiu in yc fc,an c(1 S!-`;'az-(}��--rA a f'r>-0CSIN,W IT dsy irr_ina m.. . _ e or cir;:uvtaztal u.c oily Pcrrnit Nutnb _ Si„r tureof i.ictrnc;cJl'crmt.tc. r SECTION 8 '._CONSTRUCTIION SERVICES 8.1 Licensed Construction Su ervisor: Not Applicable ❑ Name of License Holder : ci 013 G if License Number Addres Expiration Date zoo s- ture Telephone .Re ere ._ .orn m r uem'en:4..ontractor:.f -- ME Not Applicable ❑ c- �� 7 7 Company Name Registration Number Ji( A911-0 y yt, L �C.-dy D/Or a r'/ 1-"- 2 o� Address Expiration Date Telephone z?2-- SECTT 10 WORKERS' COMPENSATION INSURANCE.AFFIDAVIT(N[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 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 15") (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 i j 4 - SEGT1ON 5 D S RIP-TdON OFy:PROPOSED WORK chec16,A a I�cable x �: „ a New House ❑ Addition ❑ Replacement Windows Alterations) Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding[ ] Other [ ) Brief Description of Proposed Work: : : ,��.*w t� ov k.��J' .C.��al:�a. � awl, .�i.. aaJ A�s Alteration of existing bedroom Yes No Adding new bedroom Yes No r,6urh J Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0• Sheet 0 a:. °f e�w o: do acif'r'on.�to a istinghousin com=pie e�tiiellowrng 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. 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 1. Septic Tank City Sewer Private well City water Supply SECT37 }NNERAtFIORIZATION TO BE COMPLETED WHEN OINNERSGENR CONTRACTOR APPLIES.FflR BUILDING PERMIT S, -J �►r hi E.. GA.rJ,Q►�1 ,J , as Owner of the subject property hereby authorize h 6% �• l�l /p� •s� Z t. to ac;. on my behalf, i II matters relativ o work authorized by th,s building permit application. Si ure of Owner Date P—0114 4w1j as O1Authorized Agent hereby d4are t t he statements and infolmation 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 Sig ur of Owr"✓Agent Date Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF 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 % 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 DON'T KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 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: ... ...-.....- City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 es !v!AY - Aphis* 413-.587-1240 Fax 413.587.1272 o it APPLICATION TO,GONSTf UCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATIONsr fed This sect�o�to�t "�""Qmpfe#ecl, b office. 1.1 Property Address: Z L A c14,S(•' A rte Map Lot Overlay D15111rict � EIm�St�Dis rict _? �� CB�tstrlct� � "� SECTION 2 PROPERTY OWNERS.HIP/AUTHORIZED AGENT - 2.1 Owner of Record: --�o►vn- a. Ann C a p a.h Name(Prin Current iling ress: - o a 0/04 2- Telephone ature -113 — S 8(� ? (, Z-- 2.2 Authorized Agent:J / /i !!`` ,/ rek Pt��K Name Pri Current Mailing Address: Si a re Telephone �:SECTIIONi!3.-!ESTIMATED CONSTRUCTION-'CO"STS 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 p? This Section For Official Use Only Building Permit-Number: d Date Issued* I Si"nature: Building Commissioner/Inspector of Buildings Date' � g �! File#BP-2004-1093 APPLICANT/CONTACT PERSON KENNETH LYNDS ADDRESS/PHONE P 0 BOX 448 LEEDS (413)584-9282 PROPERTY LOCATION 26 LADYSLIPPER LANE MAP 35 PARCEL 219 001 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid Typeof Construction: FINISH REMXINING BASEMENT W/SHEETROCK INSULATION&CEILING TILE New Construction Non Structural interior renovations Addition to Existing Accesso1y Structure Building Plans Included• Owner/Statement or License 013668 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION PRESENTED: I/ 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 C ssion S /eda� 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. 26 LADYSLIPPER LANE BP-2004-1093 GIS#: COMMONWEALTH OF MASSACHUSETTS MU:Block: 35 -219 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category. PERMIT Permit# BP-2004-1093 Proiect# JS-2004-1630 Est.Cost: $9800.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin KENNETH LYNDS 013668 Lot Size(sa:ft.): 57499.20 Owner: CAPLAN JAMIE ANN Zoning: SR Applicant: KENNETH LYNDS AT. 26 LADYSLIPPER LANE Applicant Address: Phone: Insurance: P O BOX 448 (413) 584-9282 Workers Compensation LEEDSMA01053 ISSUED ON:5117104 0:00:00 TO PERFORM THE FOLLOWING WORK.-FINISH REMAINING BASEMENT W/SHEETROCK, INSULATION & CEILING TILE 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 Si nature: Feel e: Receipt No: Date Paid: Check No: Amount: Building 5/17/04 0:00:00 2687 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo � � `�� �� ��, `�• ,r't`e'` �� �.��� ��} 1�, , s { �° r-x�4 3�.>a.rr ��x s� - r•amp"+ .z' ,��r w � *'` - ,�� ��a�,� ::� , 4 €xc x 4 Rid! sa £ 5S 3 o r o' � f.x a,,aM,,� ak' a er .��'"e k�`,•F�`' `� �i':: s..a` "� � ,_., s „k,x�e k .. 'S� ?„, 3o- • 3� -k4 � 'x '�-,. fiY . a +x,�m �;x'i x:�.'�` { �",��,,, '38�� ±G^Mkt � n� ro+i'"� ^zs ae�-� •��.� .# 3a'€'��+-�. ;>k*. �,;-^ a+: -;ri,h.:^" '.�':. ,, ;.. ' .€w�.. 4�4 �" x IM „ 26 LAS GIN# Makjlock:35-219 Lot:-001 PERSONS CQNTRAC'1'ING WITEi UIwiREGI��JCERED CSJICIItACTOi ' Peen it: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A) Cate&M: BUILDiNG ,PE RMIT, Permit# BP,004-1093 Froiect# IS-201=1630 Est.Cost:$9800.00 Fee:$LO.o© PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: Licenser Use otm: KENNETH LYNDS_; .�.�� Lot Sizelsa.ft.?: 57499.20 Q1►l#er': WI AN IAMIE ANN nn;, : cu - 44 ►,tfcaret`KENNETH LYNL}S AT: 26 LAt7YSi.IIPER LANE 44gLIxcantAddressr h ie• nsura Vie.• P 0 L30 448 (413)584-2292 Wa ers !QgMpgnsafion LEEDSMA01053 MAI'lE,m,91MI-I M& ?TO PERFO "G . 'GY CS~ PENNING BASEMENT W/SHEkROCCt INSULATION &CEILING TILE ST THIS"m so f1r,119 IM Im�pectctIl #wirift I : V B I:rutor Undergroumd rr e: Utter: Foo Rough: �� j�' prlsy I3`#nat: Final: awls, fi 7/*y Rough Frame Gas Fire I3e Firep hl mey:' Rough: Oil: Insulation: ek .5 Final: Smoke: Final:d 1C Co - 21-O if THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGUL IONS. Certificate of Omupa h ' nature' FeeType• Receipt No: Date Paid: Check No:_ Amount: Building 5/17/04 0:00:00 2687 $50.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo