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25C-167 (2) N. HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction supervisor. 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 ofNorthampton wants 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 xxgnlations The inspection pro_cess 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 —_ --pennits-in-conjunctionto thebuilding permitissued, 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 pro er permits and inspections are made I, understand the above. (Home owner/resident's • ature requesting exemption) I will call to schedule a quired building inspections necessary for the building permit issued to me. Address of work location The Commonwealth of Massachusetts - Department of Industrial Accidents Ag �jj�t-- Office of Investigations il, , SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: MS1fi16 t aiANr (S -cm 4-3% License Num er V0■11014 'sl. x tt4iV b111P t 011`30 �'{-1 j >i Addre Expiration D e Signature Telephone '9..:Registered Home lmprove<rnentVbritrantor.., .. F,,x K., ..x , _>., Not Applicable ❑ 14at'k t.t:K 14'14 ilk* 5' m4a kltbaq Company Name Registration Number • Address C.W ij Expiration ate tki1`t'1A so Telephone"�1 � ��`� � 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 building permit. Signed Affidavit Attached Yes )4 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 Employers 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 Ar in��—anGeS '�a a .. •- -• . : -• i • ..° .. - . • . . -tts=GertEral-L-Laws Homeowner Signature Z-1 „-,---/ J SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacemen 1 (f 'endows Alteration(s) n Roofing n Or Doors ICI Accessory Bldg. ❑ De olition New Signs [E Decks [p Siding[04] Other[p] Brief Description of Proposed t�� t 414"114./ T ' et Work: resill�. 3* "' " - l Re G-e- �cuRG�fN .Same 40(00 N' Alteration of existing bedroom Yes /o Adding new bedroom Yes ✓ No Attached Narrative Renovating unfinished basement Yes .V' No Plans Attached Roll -Sheet 6a_If I eel tietiiseah °iieidditiiiii existiikildusitii ob'mple#e=tt e.follthirina: 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? a,[, — � 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. I. 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 L . C-i2- "T,J` ,as Owner of the subject property hereby - -thorize a r v `v to act o my beh. 1 = --tters relative to work aut' hoYized by this building permit appli ation. _ ( 1 �� l3 Signature of O ner_If Date IA/ ,as(Authorized Agent hereby declare tha 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. 14** Print e I ___ b It — 3 Signat a of Owner/Agent Date Section 4. ZONING All Information 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 Open Space Footage (Lot area minus bldg&paved parking) #of Parking Space Fill: (volume&Location) A. Has a Special Permit/Variance/Findin er'been issued for/on the site? NO 0 DONT KNOW YES IF YES, date issued:. IF YES: Was the permit recorded at the Regi of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book J Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO er DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained 0 , Date Issued: C. Do any signs exist on the property? YES 0 NO ey IF YES, describe size, type and location: D. -Are there any proposed changes to or additions of signs intendedTof th property? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb{clearing,grading,ex vation, or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. X • RECEIVED �� � t��l al �e City of Northampton Stats of� d5 4� m _ : Building Department I �D as ,tayl er ' t� ' fl 2013 212 Main Street S4u1ertSepfii�A`aibrtd}y �..la�,� 4 � , i Room 100 i Pt Ga I��,' . 4- I -- — Northampton, MA 01060 �" ` 1 DEPT Oh'3JILD1NG INSPECTIONS �Q, Q Stj"*-t#tC3zPlt 4*Y'* 1' 1�^ i� NORTHAMPTON,Ma 01060 none 413-587-1240 Fax 413-587-1272 �e-v ela' ill ` 741 45 1, APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORMATION This section to be completed by office 1.1 Property Address: 3© 0 c c Lo,,--C( 5 f Map Lot Unit N 0(".\-i At-Ay i-tV / /A'-) 010 60 Zone Overlay District Elm-St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Recor.• L / y.t --TA.-c_err '' O 0 C Ckc-c-e . ck- Name(P nt) Current Mailing Address: n (5.1 D 6 0 - , Telephone Signature _ IF /_(/ / « '113`J`J -077ti 2.2 Authorized Agent: \ 1 ft< .t)) .4 to (14,(44,t IN% C‘334 ame-(Print)-� Current Mailing Address: . — 4%—67S- 'l ay Signal re Telephone SECT N 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building t zav (a)Building Permit Fee - L 2. Electrical (b);Estimated Total Cost of `,..----- Construction from{6) 3. Plumbing -N....../ Building Permit Fee l'''' 4. Mechanical(HVAC) _ 5. Fire Protection `�.1 - . 73 6. Total=(1 +2+3+4+5) `� b C.- Check Number 1, 111J This Section For Official Use Only Date Building Permit Number: Issued:, Signature: Building Commissioner/Inspector of Buildings Date File#BP-2013-1234 APPLICANT/CONTACT PERSON MARK LANDY ADDRESS/PHONE P 0 BOX 61 ASHFIELD (413)625-6999() PROPERTY LOCATION 30 ORCHARD ST MAP 25C PARCEL 167 001 ZONE URB(100)/ THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out �T Fee Paid T Typeof Construction: REPLACE S ING&PORCH(SAME FOOTPRINT) New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 077431 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO TION PRESENTED: pproved 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 Commission - Permit DPW Storm Water Management Demo • ion Delay Ojr--91111F 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. 30 ORCHARD ST BP-2013-1234 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C- 167 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:renovation BUILDING PERMIT Permit# BP-2013-1234 Project# JS-2013-002037 Est. Cost: $15500.00 Fee: $93.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: MARK LANDY 077431 Lot Size(sq.ft.): 8319.96 Owner: MARCHAND SOSHANA&LUKE JAEGER Zoning:URB(100)/ Applicant: MARK LANDY AT: 30 ORCHARD ST Applicant Address: Phone: Insurance: P 0 BOX 61 (413) 625-6999 0 ASHFI ELDMA01330-0061 ISSUED ON:6/21/2013 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE SIDING & PORCH (SAME FOOTPRINT) 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: Date Paid: Amount: Building 6/21/2013 0:00:00 $93.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Louis Hasbrouck—Building Commissioner