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I i \ it --,...................0..... 1 , 7.1...... \ .1"..., �tiAMP7. , 4�0 �_� ; Crzty of Northampton _ =*=.. _ —_.... ..x_5y"-� DEPARTMENT OF BUILDING INSPECTIONS 1 __� /_ 212 Main Street • Municipal Building INSPECTOR '>a,V Northampton,MA 01060 S,. ` 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,'ssgr. 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 wilding department"for the City of Northampton wants-any persons)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 % ,/, j� � JAi i� � understand the above. (Home owner/resident's signatuee requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date l —,2o-—Ob Address of work ��``�� � location 4/ , �/,Q / -4i,f -Zl J� C1 ^_ " ' 714,(0, // /�,,/'7 _ _ 4 • • r g{o C)4- f r (L-1r of N 0 zamjto11 •R )' i sy • DEPARTMET.fT OP BUIW1} G INSPECTIONS 212 Main Srcct Municipal Building Norlhampion, Mass. 01OGO es' 1 WORKER'S CONLPENSATION I1'iSURA–NCF Al,1 U)AS.\''Y i (liccnsxJpc n ttet) \}.rich a principal place of businessfresidence at: (phoney=) (smr>JJdty/stalLfrip) do hereby certify, under the pains and penalties of perjury, Lh i i { ( ) I am an employer providing the following!worker's compensation coverage for my employees worlsng on this job: (Lturanc Coocanv) (Policy Nurni r) (r.t-piration Dale) ( ) I am a sole proprietor, general contractor or homeowner (c c:e one) and have hired the contractors listed below who have the follow-MR worker's compensation policies: (NII1n: of Contractor) (Insurance Cornoariy?oUc Nuen=Cr) (Y`:nirauon IDnIc) Mme of ConDactor) (Insurance C-omoa yPoiic- Nuac_r) (1:,piston Dais) (Name of Connaaor) (l.msu.ranca C-ompany[PoUcy Number) (Eapirtion Dalc) • (Name of Contractor) (Losurancn Comcany/Policy Number) . : (nCSCb a itio5!> cG.;tnr.,--...-ti•t anc?u.&;afoa..noo pcu.i to.11 ooc--.c..o:s) I _ ( ) I am a sole proprietor and have no one woring for me. I am..a home owner performing all the work myself. • NOTE:plc.-cc be ca-arc tfi+•Maio bocaccrwocra who cL„^ploy pc^..ons to do r ^-,V ,cs croo c rc,^-t.it+writ oa a dw.X1 of tux ezore tins t`toe ter+is cr'b;th the bomocrwo• raid=or oo the a ou-nd,:p•p,u-tcaaa tbo- .o iT ox to be c:rplo •ca uo'c thc.. c=p....—.,.ion Ac (GL152,=1(5)),.ppl;-'7aa by n bomeoCv="fc a tic_a pcmit r✓y nid�x tl~ Ic•gs.t e.^,•of ea a cloyx wader dao Wor'celc Coc,.om.iion Act_ I tandmsurad Mai a copy of Ltd" may be forwarded to the Dcpertoco e of loci rs;r1 AL-Odd'Off oe of Irra+rcoao for the cove-r.9•-c vciGaiioo cad t1t c CLihn-t to soctrc toVoracc met—s ation 25A of MOL 152 cum 1Gd to the in/;:acid=of eioimil p•-r0t;a of a floc of to S 1.300.00 o J0c °oo�s=xzlg up i=cpetsoameat of up to ooe yr:r e.ad c vi1 pm2.1•ua in'.r forth of•Stop Wort.Or end• fir:of S 100.00 a d_y actin coc. / u+c only --------�-- Foryt �� �' t`< i' Pcrmlt NuIDbcr — Si nature of Li=scrJPcrmiu B- e _- -- • SECTION 8-`CONSTRUCTION SERVICES f • 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone Not Applicable ❑ 9'A dW ragati' r prove lento rttra o%I ;: :; cam, 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 ❑ No ❑ i u 14 4- omeswwneriMemption 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 General Laws Annotated,von 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 t SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑. Replacement Windows Alteration(s) Q Roofing n �- —�/ Or Doors 0 ED E Accessory Bldg. Demolition 21 New Signs [D] Decks [0 Siding[0] Other[C Brief Descriptio of Proposed Work: ��,otAC�' AtaSmL-L. AJertir c.5Netw.-iz_ Zw,r'` t<1rls °-/.Aeyt i u. etirrAerwi t ;2i,�a ,s zrat Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓�No / Attached Narrative Renovating unfinished basement Yes ,/ No Plans Attached Roll -Sheet 6a:if N`ew housean&or c11>ion`to extstinctiousirlq omplete.�th fo lowrnct:. a. Use of building:One Family ✓ Two Family Other b. Number of rooms in each family unit: .3 Number of Bathrooms o2 c. Is there a garage attached? ,JO f}ooma d. Proposed Square footage of new construction. ')/A 'SP�fCE V Dimensions e. Number of stories? N/�) Cam..,-7.:� f. Method of heating? Zct V /41 r tci fireplaces or Woodstoves Number of each pe g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction c Z c)i' lG4 i;?.061t6 / 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 Atinp.e0,N7"/".7- k. Will building conform to the Building and Zoning regulations? ✓Yes No. I. Septic Tank City Sewer ■/ Private well City water Supply L/ SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT -44/a0 .. %j (17K ' ,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. Al —?, - " / Signature of Owne Date Aar I C 'd�� �^� ,as Owner/Authorized Agen�reby dec are that the s"4/////7 ents n d infotthation 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 Owner/Agent �� f J iAraM ,, Date — , 40 6 "1Uo r- !7194)/ ,5r'AC6" — . ci.,o.[t.eitJ i,5rrd ly ,sAc.� Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department • Lot Size Frontage Setbacks Front , Side L:: ' R:::______2. L: R:- 3 Rear f Building Height Bldg. Square Footage l F Open Space Footage (Lot area minus bldg&paved „_,_ parking) 4 #of Parking Spaces Fill: 7------ (volume'&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DON'T KNOW 0 YES IF YES, date issued:, /V-5.v: vZ I IF YES: Was the permit recorded at the Registr of Deeds? NO 0 DON'T KNOW YES CI IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO er DON'T KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 , Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: { D. Are there any proposed changes to or additions of signs intended for the property? YES Q 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 0 r NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department use only City of Northampton Building Department C ® ways 212 Main Street Sev c qtr ° airy r r.(�h Room 100 _ i`1%. L Northampton; MA 01060 5 r�i ?aras �� phone 413-587-1240 Fax 413-587-1272 _ 4 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: Lat Unit L�7�S ,,e/9 - c<a 5 3 done Overlay Dlstrlct Elm St District CB A,istrict SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: TZiV�1 D S -oj LC 1,! &.L =E rg.' 1a.53 Name(Print) r Current Mailing Address: cf,�/'(/ `'t�-�-• Telephone Signature 2.2 Authorized Agent: SAi'1E AS if rsil� � srrc 4f 3� 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 em?, arc o (a)Building Permit Fee 2. Electrical - © (ti)Estimated Total Cost of Construction from(6) 3. Plumbing �CjL7.co jzr,od Building Permit Fee 4. Mechanical(ri VAC) 5.Fire Protection A.04 iq 6. Total=(1 +2+3+4+5) 0?� 9 �•co Check Number �0 k -0 This Section For'Official'Use Only Date Building Permit Number 'Issued:_ Signature: Date Building Commissioner/Inspector of Buildings File#BP-2006-0752 APPLICANT/CONTACT PERSON STANLEY THOMAS E&LINDA A ADDRESS/PHONE 4 HEFFERNAN ST LEEDS (413)584-8146 0 PROPERTY LOCATION 4 HEFFERNAN ST MAP 11C PARCEL 005 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out ,q� Fee Paid c77 0.9 !Y — Typeof Construction: REPLACE BATHROOM SHOWER&RELOCATE WASHER&DRYER 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 INF RMATION PRESENTED: 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 Co 'ssion A 7 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. 4 HEFFERNAN ST BP-2006-0752 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 11C-005 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2006-0752 Project# JS-2006-1154 Est. Cost: $2950.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.ft.): 17772.48 Owner: STANLEY THOMAS E&LINDA A Zoning:URA Applicant: STANLEY THOMAS E & LINDA A AT: 4 HEFFERNAN ST Applicant Address: Phone: Insurance: 4 HEFFERNAN ST (413) 584-8146 0 LEEDSMA01053 ISSUED ON:2/10/2006 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE BATHROOM SHOWER & RELOCATE WASHER & DRYER 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 2/10/2006 0:00:00 $50.005109 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo