24C-121 (9) - za
City of Northampton
Building Department
- - 2f2 Main Street
_ 1,. Room 100 - a
Northampton, MA 01060 '-:,--7.77....
l�n.l 2p�to[I!: 13-587-1240 Fax 413-587-1272 _ ' F �+
APPLIEATION-TO.CONSTRucr,/LLTER,REPAIR,RENOVATE OR DEMOLISH A ONE ORTWO FAMILY DWELLING
SECTION 1-SITEINFORMAIION
1.1property Address: r�, m „ + ,meq, �' > A
Vilyr .�;,ee,( .-,�
peRTNRMel— Mfg al
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SECTION 2-PROPERTY OWNERSHIP/AUTHORIIED AGENT
2.1 owner of Record:
Name�Ppntj Current Mailing Addres:
jg 1 Sr/ 'D`/ 7 ci
COLA r X _hr _r_ / Telephone
Sig re
2.2 Authorized Anent:
n G
I is IZ ( L4 alt-r-' d-O— c S I '�rJ �j./� /�}1 LS
Na Pn ) Current Mailing Addres:
ll/� Lc,�z / Z G `3 W `S �l �O g
Signature Telephone
SECTION 3-ESIIMATEOCONSTRUCIIOWCOSTS
Item Estimated Cost(Dollars)m be . officialusedrily
completed by permit applicant --
1. Building 6 �^ -(a)Building Permit Fee
2. Electrical 1 l./ (bj Estimalei Totai Cost of
Coma tion fmin(6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fre Protection
6. Total=(1 +2+3+4+ 5) -(31erk Number 7gi ✓
This Section For Official lfse-only
Building Permit Number: Date Issued:
Date
Signature: .. _
Building Commissioner/Irtsp�tor of Buildings
Section 4.
ALL INFORMATION MUST BE COMPLE IED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This colusm in be filkd in by
Building Deparmat
Lot Size
Frontage
Setbacks front
Side L: R: L: K:
Rar
Building Height
Bldg.Square Footage
Open Space Footage %
(tut urea minus bldg&pave
poking)
Ii of Parking Spaces
Fill:
(volume&Laotian)
A. Has a Special Permitryaria ce/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES, date Issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW
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
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:
1
'1a T it.:;f a "E >r O ,e ED+i OR ct -t-a li
New House 0 Addition 0 Replacement Windows Alteration(s) 0 Roofing 9
Or Doors pit
Accessory Bldg. 0 Demolition❑ New Signs [ ] Decks ( ] Siding 1 2 Otherh [ )
Brief Description of Proposed Work: Wk nd1„w5 / .57704 - S::`.if- Av>GL Per2cAC-
Alteration of existing bedroom Yes No Adding new bedroom Yes X No
Attached Narrative 0 Renovating unfinished basement Yes >Sy No
Plans Attached Roll D i Sheet D �
INSEd`dl rD o eztgtiri£ahot till ...-at a ez TMAt a:
a, Use of building: One Family y 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?
L 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 .
I, Septic Tank— City Sewer Private well City water Supply
o k. e �"d O ORILA .ON TO.BE CO(dSL D 'HEN _
K®Y,'� `�".a'. O :F�AGTOR APPLIES,'EOR BUli tNG?ER T .`"." --
,; t, / z A n `—'e7 Lki f 'b , as Owner of the subject property
hereby authorize M R 6Lk L.A Z.4 r‘le. to act or,
my behalin all matters relative work aut prized by this 'building permit application.
_&) C 1 a
Sire:Owner Dat
� �� � '�
I, , 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 paips and penalties of perjury.
1P Pit
Prin Name
ignature of Own /Agent Date
SECT3D0-26210TRDETIDN SERVICES _
8.1 Licensed Construction Supervisor:erNot Applicable ❑/ �t —f
Nameof License Holder: MARK 10At4/(0cs 0 �S !0 7 1
n p f� , Cit
License Number
Ag ey S 1- 71)AmigkS F4 I-{-5 Ai i" °/57 C
1219\ 1 J a Oo (.,
cAddress r t, Expiration Date
/A�� VI S �Cn 9 � � 8
SI ature Telephone
a e s ": Ara=ate= 'r'ont'et. o-- + ,='„ Not Applicable 0
Company Name Registration Number
Address Expiration Date
Telephone
EGr *.�94WORElffi-COIVIPENSA'71ON.3NSURANCE-AFFIDAVIT(ht: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 0 No 0
1000 .0 Cart. i Liit 0 iiyeiTri 00701st Or tit
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
•
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yj i U,iiF) xii' '.n-tli�lltl}�falti= —=
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UEPI li)•fENr OF BUILDING INSPECTIONS
'�1r
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE .ADT'IDAVT
1,
(I_ s: ti -) __..._
nvi,h a principal place of busi, ss/r dent^
(a,�r)�,%,:r_a>,p) —
do hereby certify, Linc Cr 'Mb pins and pen l:ir; 01 perjury, that. -
() I n an employer providing the foJ owinc '::orkcrss compcns=Lion Covera.c for my
employees working on this job.
(Insvpance Courpny) (rb•in Number) wdaritden Darn)
O I am a sole proprietor, general cmnsccr or homeowner (circle one) and have hired
the contractors listed below bbho have, the folio-r worker's oarootabbaoon pubchts:
Tamc of Contractor) Qnatmacc Cama::;;.!?olio Numb r) -nt:ca Data)
(Name of Contractor) thasurarets Como-raw-Poi icy NumFi.r) ffaaatiaaaan Dare)
(Name of Contractor) ilasarancte Cas oneo5,e: NImh_;) r_) sc_Date)
(Name of Contractor) (insurance CourrinoTonaoc Nuclides) L ,un Date)
(K I an a sok proprietor boot have no one V orkini, for me
( ) I orn - home obbocr orribormilr, -. IIthe -
NOit:picAsc In n1001144: - t
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in y 4 - n CX Ot: • r LhcC rvr all . r 0__
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e.akda w.T - ,m.
I LLedc.reAnd LIU'.a ccrey of this[Iaie.-s svy be fon;.00.-J 0 n�l}tyuryn of IncE400j Am/0:S c:flc of::0, : for O
mVU-AaaSafw r4 n+s Glum to, "at aJr.25A of 4.101..152 an la!to J+c lmpatiucofc_=iJ pvI::
e :aRra i
cA
CDeiE ca or fin.:of up to S13000spe rr c_pritr_-c. of::p in Cr..r.„-.:.1 dvil;cnrltio in]c:euro f.Seq.)C*T:>t-.1c
Gro of SI O0.W a thy 1€4.0-.1 nae
For Ju0 ly
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C itg of Narfliampton '—l =,
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DEPARTMENT OF BUILDING INSPECTIONS ''r 1I
fNSPECTOR 217 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 super,''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
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