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32C-121 (12) ¢t1AMA?, =iwO = fl _ _,22 01-it of Paz#lri} ctt jiiA assachusetts :: =-411111 '�"``� DEPARTMENT OF BUILDING INSPECTIONS - _'•.;={ /? INSPECTOR 212 Main Street • Municipal Building '>a 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: .. 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 ti- .roper permits and inspections are made I, tJt ', understand the above. (Home owner/resident's signature . 'nesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date 4 ((e) Address of work location '1. 0 i S 1' 1Vti.44,■..-..--(3h7 A it" '‘ F�...0 ., E1•.-,. ' (riff of �rrrf17 i11}�to>� 1 `w ja rt. `t `, 0. , = - DEPARTMENT OP BUILDI'G INSPECTION'S 212 Main Strcct • Municipal Building+ Norlhamplon, Mass. 01060 ,. too V-T'ORICF.R.S CO MT ENS A`IION -ENSLr A' CE Al,rFiJ)AVII' I, -- —.- --- -- -- ...._ __ .,_....._ .. ... ._..-- 1i cLUSXipermi ttee) with a principal place of business/residence at: _ • (phone') (writ/city st:a.tc!zip) do hereby certify, under the. pains and penalties of perjury, that ( ) I am an employer providing the followins, worker's compensation coverage for my employees working on this job: aasurnc Comnam') (Policy Number) (E:-pir`tion Daze) . ( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired the conmactors listed below who have the following worker's coonensadon policies: (Name of Con,:racior) (In uranc; Coinpany1Pouc, Nu.mL-(r) ("EXJliocion Datc) (Namc of Coop-actor) (Insurance nce Company/Policy Nu.s ccr) (i:»ir Lion Date) (Name of Contractor) (Iasuranec Company/Policy Namb r) (Expiraon Date) (Namc of Contractor) (iasuran Company/Policy Numb r) (Ex-pintion Date). (aaac:t itioc,J t Y1,lf ncccto v to into&inforc oo pcuiniag to.11 0007---cots) . t O I am a sole proprietor and have no one worinng for me.m ) I a .a home owner performing all the\'Iork myself. NOTE:pI oc be earire the wt )c beancov--ocrs..bo cmpIcy pc-soar to ctn r-,%nom-,. =s--tc-loo c rcpas work on,dh•cJLg of ao(morn th n tiro:unit+in which the borocerwac r,oido or co the grouac l:.ppr l occ.rn tbe- .o c-c ont c-me-41y omidaod to be esstpIoye-s undo the wtx$u s cr o..-.,;c Act(G LI52-n 1(5)),r ppltatioo by a homeowner fa c 6c __or permit try csidcocc the Ic-gal rt,n,c or as cnployer uodcr the Wockcic Coorocecu.L'oo.Act_ I uadc-o d that a Dopy of thy.ent.®rm may bo forxerd.d to the Dcpottmma of 1.-A■rriJ Aoodos&Ofrroo or to=u-•ooe for the oova'asc vctif atioo a_•1d tttu L-iltac to smut Icovcsa se'rode-,section 25A of MOL 152 c3a 1=4 to the monition of eimiast pcaaltia ooasismg of a Sae of-Up to S 1}00.00 ar,dfor imprisommc=of up to occ yo r a.od evil pea ilia in be form of a Stop Work Ordc and. rrmo(S100.00t day a: . 411k� For dcoota.-.-at u.c only �. ( Pt:TIDIt r`I lln]tJC7 +. ).1,p: ►Ate Szgnat Hof a�i •crirulice SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone "Rern`seredlomelmproemerit writ aria .7'" s :> Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 1 0-'WORKERS'COMPENSATION INSURANCE AFFIDAVIT 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:Per-son-(s)-who-o-wn-aparcelofland 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 . . oc 1Z.• : ••ws and State of Massachusetts General Laws Annotated. Homeowner Signature ,� SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) I New House ❑ Addition rvr Replacement Windows Alteration(s) Roofing n Or Doors 0 Accessory Bldg. ❑ Demolition ❑ New Signs [E) Decks fCl Siding[CI) Other[0] Brief Description of Proposed Work: (kcvy. Qlh+,5 tv iAt4(r tt A((ORr1 0110.1—.. Alteration of existing bedroom Yes "No Adding new bedroom (.../-Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet s�ar.9�if,N • F orlSe a= • , `.atiltlon tocexlstr latITetiqf for t a I/a o it li: a. Use of building:One Family Two Family Other / Triw.,I1 C�>+I" At I essO"7 np� ' b. Number of rooms in each family unit: 9? ,11 Number of Bathrooms % 1 c. Is there a garage attached? AJJ d. Proposed Square footage of new construction. /2-©0 Dimensions e. Number of stories? f. Method of heating? fte fi✓h �►'sz.✓ l+` A i r Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction NI&'J i. Is construction within 100 ft.of wetlands? Yes .-4.1o. 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? t/'Yes No. I. Septic Tank • City Sewer Private well City water Supply -SECTION;7a -OWNER,AIFTHORIZATION TO'BECOMPLETED-�WHEN- OWNERS:AGENTOR CONTRACTOR APPLIES FOR "BUILDING PERMIT ..------1, w c 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, b c1 ,as Owner/Authorized Agent hereby declare that he 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. Print Name ,...-;-------- 7/ er/24/ 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 i i /0,c�O 5f , ! 0 Vet) Sc .__._ 0 Frontage /00 t ^ too' Setbacks Front /�, ; k 1 FIZZ) Side L: 0 i R: S1' L: 0 R: 51 ! 7-757 __7 Rear 20 `24' 2,0 Building Height 7-----T-1 !2;-, 1 tj .fir t")�f�1 Bldg.Square Footage % °.r i ne,� ( Open Space Footage t �— �!�� (Lot area minus bldg&paved O 8 p3CO '3 I s 3D2 parking) #of Parking Spaces L Fill: i _ (volume&Location) A. Has a Spec'.I Permit/Variance/Finding ever been issued for/ n the site? NO �h' DONT KNOW 0 YES IF YES, date issued:] 61 231(a i IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: * enter Book (07q( i Page; 33-T and/or Document# B. Does the site contain a brook, body of water or wetlands? NO cDONT 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 er IF YES, describe size, type and location: ji D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excav n,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. � Departmen se bI ,z #("41,4v/ / Ity of Northampton Sta ®<: ��k Building Department j 212 Main Street �E �-�� 4 7: st.V t Room 100 •t � � Northampton, MA 01060 _ phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION:1 -SITE-INFORMATION Thissection to'be completed i4office 1.1 Property Address: * J n h 1/. , N ZOlie © eday District ,' 'Im:St.DAstric't ' SECTION 2-PROPERTY-OWNERSHIP/AUTHORIZED;AGENT` 2.1 Owner of Record: Name(Print) _—m • Current Mailing Address: lei 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 (a)--Building.Permit Fee 2. Electrical c�CJ (b)Estimated Total Cost of . Construction..from(6) 3. Plumbing ��` Building Permit Fee 4. Mechanical(HVAC) 5-e O 5. Fire Protection 6. Total=(1 +2+3+4+5) _ („000 0 Check Number This Section For-Official'.Use-Only Date Building Permit Number,. Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2007-0092 APPLICANT/CONTACT PERSON DAN JEFFREY A ADDRESS/PHONE 20 FRUIT ST NORTHAMPTON (413)575-1932 Q PROPERTY LOCATION 20 FRUIT ST MAP 32C PARCEL 121 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out /✓� 2 ?D Fee Paid i 631/1 Typeof Construction: CONSTRUCT 2 STORY ADDITION ACCESSORY APARTMENT(2 BEDROOMS, BATHROOM&LIVING SPACE/KITCHEN) 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 INF9 IATION 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 ion "el/26116 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. • 20 FRUIT ST BP-2007-0092 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C- 121 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: ADDITION BUILDING PERMIT Permit# BP-2007-0092 Project# JS-2006-001810 Est. Cost: $54000.00 Fee: $631.90 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 10497.96 Owner: DAN JEFFREY A Zoning:URC Applicant: DAN JEFFREY A AT: 20 FRUIT ST Applicant Address: Phone: Insurance: 20 FRUIT ST (413) 575-1932 () NORTHAMPTONMAO1060 ISSUED ON:8/9/2006 0:00:00 TO PERFORM THE FOLLOWING WORK:CONSTRUCT 2 STORY ADDITION ACCESSORY APARTMENT (2 BEDROOMS, BATHROOM & LIVING SPACE/KITCHEN) 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 8/9/2006 0:00:00 $631.90736 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo