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06-006 (2) o1 IMPS, . � " , (City t f Ncztli&niptrn • 01.2 =*_ i . es if ELIIM ;,i► s'.i(! JAIassaci1usetts MI 1— DEPARTMENT OF BUILDING INSPECTIONS _ INSPECTOR 212 Main Street • Municipal Building a��=S`�,` 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 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 AY the pro ct until such time as the proper permits and inspections are made 2--,,,,__ ,--.)cr I r f — k-t- 1 .01L-e W 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 7/)1 ici Address of work location (,)7 '9 �t /` - CTh 2c gt,e4 o /o e_C; o,,, pi..-cl,LA.-f A� - _ !E Si 17 Cr Northampton 4 � �� 'y� l 1 = l - Q tyrj / E - glzoattrtincrlta' •. w�sti ,, - _• L���y� DEPARTME1J7 OP IIUILDNG INSPECTIONS • - - • 212 Main Street ' Municipal Building Northampton, ,..7. 1~orthampton, Mass. 01060 te t rORtGi R'S CO NCI'ENSATIO N INSURANCE AFFIDAVIT 6,,.-1-----,, _.... r r r■ I. -L: 7L__ (Iicmnsxipermittoc) \vith a principal place of business/residence at: . (phoney') (sue-t/city/statcf ip) do hereby certify, under the pains and penalties of perjury, that • ( ) I am an employer providing the followino, workers compensation cove age for in}, etuplovices woddng on this job: .. (Insu_r2nc Company) • (Policy Numir_r) (r;-pinion Daie) . ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the conuactors listed below who have the following worker's C oonen ation policies: (Name of Contactor) (Insurancc Cornoanyi?oUei Numb r) ,:airuuon Date) -- . (Name of Contact sar Contactor) (]naacc Company/Policy Number) (Eimiriion Date) (Name of Contractor) (Insurance Compa.oy1Policy Nambc.r) (Expiration Dale) • (Name of Contractor) (Losuraflca Company/Policy Number) (Expiration Date). (fal..unb add ocil Mem if ococsr:y to'coca.iaforo. oo pertaistiac to all cones-ors) •( ) I am .a sole proprietor and have no one wori;3ng for me. I am-a home owner performing all the work myself. NOTE:plcx be nowt tt,.k4:Jc bcmco•.vcra wt>o employ pcwm to do -i,-,••,.• cas.r,00 c rat,air stork cra.d..ctl_`of aot tacit thz throe tmitr in which ttac bomoowoc raids or oo the ,-ounrt-r z,-rpurtcanrl th ..o ter oat C--k:lty occ rid=d to bC employ=t,nt,—the wcekcez ccmep---,:oa Act(GL152.s1(5))-r pptinnion by a boo fey c ticncoe cc permit n_y c-,ido«the Icipa to of ea esploy.w uoder tho Wortial.Coon ocealioa Ad. 1 vadariaod that a copy of this c temrro may be foe,.-o i.d to th.Dop.rcoeoa of ln&.tsicl, nn'Offtoo of Inn r cice for th. oovc- c vo-if-ctioo o--td tlu L-iltac to smut bovcrasc tmdc soction 25A of MOL I 52 ca tcd to[be ix;olitico of o-mina!Pc-aali7° com- io Oil ftoc of up to S 1300.00 sold/or of up to ace yczr cad civii pcad ie in tt,c form of a Stop Work Ord=mad a Cu=of S100.00 t day.Faint Inc For dc�...nr: u,c only ( / JC.� / 1.fap:__ Lot " is e Si�tt of Lia�tscrlPcrnvucc . II:: SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable X1 Name of License Holder: License Number Address Expiration Date Signature Telephone 9.Realstered Home Improvement Contractor Not Applicable ?`L Company Name Registration Number Address Expiration Date Telephone 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 0 No 0 11. - Home Owner Exemption 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 1083.5.1. 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 L cal Zoning La d State of Massachusetts General Laws Annotated. Homeowner Signature ea/lZ1 .. • SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors D Accessory Bldg. El Demolition ❑ New Signs [DI Decks [D Siding[D] Other[0] Brief Description of Proposed i f Work: 4-nAl e X ✓ S610 in Le 12..00 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet ea.If New house and or addition to existing housing, complete the following: 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. 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 I, ,as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date I, 13E— 4.. (-' I pi fie ' ,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. E l f l2 L.- t /11 v—e-2 Print Name 7/i I o(, --e■CL - ‘" ---.6.6.%"2--L--•Signature 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 Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/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 0 DONT KNOW 0 YES 0 IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW © YES O 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 O NO O IF YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES O NO 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 O NO O IF YES,then a Northampton Storm Water Management Permit from the DPW is required. • Department use only City of Northampton Status of Permit: Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO 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 by office 50 Z Y7 1...1-Z 0.O/3cO Map Lot Unit *\ A 0 1 O' 3 Zone Overlay District i Elm St.District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Pe''re 442-■ D ZTePitrl Fu►/4Y-e d2. a}, -DeNsuiue awe Lah5 Name(Print) �-- Current Mailing Address: L�� 5 �2'4 Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building 4 4 , 000 , - (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) ` 4'Q) 5. Fire Protection 6. Total=(1 +2+3+4+5) +4 , a-00 "' Check Number . (I(2i�> This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2007-0054 APPLICANT/CONTACT PERSON FLINKER PETER A&STEPHANIE J ADDRESS/PHONE LEEDS PROPERTY LOCATION 502 HAYDENVILLE RD MAP 06 PARCEL 006 001 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid tluilding Permit Filled out _ �ePaid "PV Nl-9 ZS .CZ) Typeof Construction: Strip and replace roof New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFOMATION PRESENTED: 1.--"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 Str t Commission 7 07 l �� 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. 502 HAYDENVILLE RD BP-2007-0054 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:06-006 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category BUILDING PERMIT • Permit# BP-2007-0054 Project# JS-2007-0075 Est.Cost: $4000.00 Fee: $25.00 PERMISSION IS HEREAY GRANTED TO: Const.Class: Contractor: License: Use Group: HOME OWNER EXEMPTION, Lot Size(sq.ft.): 162914.40 Owner:_ FI,tNkIA PETER A&STEPHANIE J Zoning: SR Ajpliwunt_F=l,l t KLR PETER.A & STEPHANIE J AT: 502 HAYDE:NVILLE RD Applicant Address: Phone: Insurance: LEEDSMA01053 ISSUED ON:2944006 0:00:00 TO PERFORM THE FOLLOWING WORK:Strip and replace roof POST THIS CARD SO IT IS VISIBLE FROM TIIE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter Footings: Rough: Rough: Rouse# Foundation: Driveway Final: Final: Final: Rough F;awe: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final: OK 124°$(D LO`S`S • THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES-AND R ULAT ( NS.--1 • Certificate of Occupancy _ _. nature: / FeeType: _ ate Paid: Amount Building 7/14/2006 0:60:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (4;3)587-1272 Building Commissioner-Anthony Patillo lr.