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32C-128 (6) Gl ity of Xort4autp#ou �I dS5AC1(itBCttd s y DEPARTMENT OF BUILDI7\TG INSPECTIONS ,t INSPECTOR 212 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 supc , 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, lf,11,1 understand the above. ( ome own r/r ide is signature requesting exemption) I will call to sched e all required building inspections necessary for the building permit issued to me. a Date J Address of work location, I�PL U I F . YY- � 0 A) i ZL 6 lslasexcltusrtIs' "> DEPA-RT1.1ENFF OP LUILDIl G INSPECTIONS 212 Alain Street ' Municipal 73uilcling Northampton, Mass. 01060 WORKER'S COMTENSAT'ION INSURANCE AFFIDAVIT :rit11 a principal place of busmessh(esldencc do hereby ccrtiiy, tlnaer the pr:Ils and pen;hies 01- perjury, that: I am an empioyer provi(llrl, the iollovviilL '•:Of'kers C0IIIPC11s2I10D COVCra"•C for Iny cmployces working on this job: oms-'L C: Number) --- �'Ex#rz on Date) ( j I awl a tole proprietor; gen-ral or homco,,-Iemer (c de one) and :lave hired tti' contractors listed beiov, tit:'o h-.c t11e oll �� porkers compensation R:tLLLC Of CO l[11CiG') (�I15'��I.1C L CI PGt1Cf Nll3lt i) (T?'; . ..IOP DdtC) (Name of Contractor) (7]slr,_nce Coy parn'/PG!ic; Nur.]rr r) 01',D r;:iIoa Date) (1 flmC of COI1tT3CtOr) )_mate) - (Name of Cont—actor) —- (ins-uanc- ComramtiPolicy Tvtumi,_r) (E::ri-:;K- Date) l 1 iun la :;UIC ]roplit"oi and ha''c r ; 1 l 4 no oI 111 a home ov""IC. NOT K:Please be awz:c Liar �.ilc lxt;ca ti:r... -o c:plc;;r.-._ a;: ::�c ,cc c =n C•c cr:c:a t c,•:,,r �uc1!ir not morn th_o dime unity in tot ct Fx 1 r.1� .1i e r :':=c-a; ` �._;.�z tur c: 'Lh�C.o a c cxt Ccrfally employes uus the tvca,a's cc --._..rn PC((�1.15�Y 1(511. ,...a; ry •.'; �•: a hnrtrot,�cr` e' legal etatus of an c2cployer under tLo Worlcc+'. ocL,oral}oc �.cL I I u.ndc---stand thL i copy of du'. c"y bn fcn}%' Ii J to tln CYji ti—e of Irwi ri_1 Mi,, ey Cflj o of i:lv."—_o for tlx covcra&C vcificriioa and that failure to r-z c cove ,ur.�: tC,ir 25A d M01,152 an lid to tlx inil±osition of c�ir-1 pct aL:ca c'omisting of a fimc of up to s1-SG -Oo a:raJor t^::tilvxZ;c:_oft.,;)to rr.:y,_;?-.1 civil poi 16=in U14 Soon cf a Str,, _r.d n firm of S100.00 a day araiwl m:. For-dq uu:ntsl u.e only SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Regt"s"e "bni imp ovement Con „ ,, Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10 WORKERS' COMPENSATION INSWNCE AFFIDAVIT(M G.,L.,c. 152, §.,250(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: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"homeoNvner"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"ce ifies and assumes responsibility for compliance with the State Building Code,City of, Northampton Ordinances, State d cal o 'ng ws and State of Massachusetts General Laws Annotated. omeowner Signature r SE TdON �D SCR AST OTVOPROPOSfD1M1/O:RK checkfla Ifiable a � New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ DemolitionCY New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Wor�k:� Alteration of existing bedroom i/ Yes No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0 - Sheet 0 6a, �fe�" e `"�`do ,�"�d:i�tron to�stin=�h uo srn""�o`in" 1, e�e.ttiefol.lo�i.rn 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. 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 1. Septic Tank City Sewer Private well City water Supply SECTION? INNER AtJTyHORIZATION TO BE COMPLETED WHEN F, APP FOR BUILDING PERMIT 1, `�'`��!•7 '�✓,�J V p� % ` f l/ as Owner of the subject property hereby authorize to acT. on my behalf, i 11 ma ers la ,e o w aut orized by this building permit application. Signatur of caner Dat Y— 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. Print Name ' Signature of Owner/Agent Date i j 1 Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size I Frontage Setbacks Front I I 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 DONT KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DON'T 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: A City of Northampton �t i g Department �f Main Street j ) om 100 ' AUG 200 o ton, MA 01060 1p�one 413- - 240 Fax 413-587-1272 ` ,.x t 111 _ ..... I APPL 1 !QO1N LTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION i SITE INFORMATION, " Thrsseckio t+ Aff�ce 1.1 Property Address: �3 � frn `ZFkI117 emu+ ' t� s y SECTION-2-PROPERTY°OINNERSHIPJAUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone , r 1 ; ,+ Signature � 7 (.�� �tl � r 2.2 Authorized A en . Name(Print) Current Mailing Address: Signature Telephone SECTION 3- ESTIMATED CONSTRUCTION.COSTS Item Estimated Cost(Dollars)to be Official.Use.Only completed by ermit applicant 1. Building ��, C .(a Building it Perm -Fee 2. Electrical ,(b) Estimated Total Cost of Construction from: 6 3. Plumbing 0,141in%Permit'Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 +2 +3 +4 + 5) 1,°Check Numiier ` This Section:For Ofrrcial use-Onl Building Permit Number: _ P��S� Date Issued: i Signature: j Building Commissioner/Inspector of Buildings Date s File#BP-2005-0188 APPLICANT/CONTACT PERSON JOHNSTON LELAND P JR ADDRESS/PHONE 42 FRUIT ST NORTHAMPTON "( qq ;Zo PROPERTY LOCATION 42 FRUIT ST MAP 32C PARCEL 128 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: REPLACE BEDROOM CEILING New Construction Non Structural interior renovations Addition to Existin¢ Accesso1y Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION 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 Con iss' ., 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 42 k6 ST BP-2005-0188 GIS#: COMMONWEALTH OF MASSACHUSETTS 32C- 128 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category BUILDING PERMIT Permit# BP-2005-0188 Project# JS-2005-0211 Est.Cost: $800.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sg.8.): 8319.96 Owner: JOHNSTON LELAND P JR zoning:URC J-pplicant: JOHNSTON LELAND P JR AT: 42 FRUIT ST Applicant Address: Phone: Insurance: 42 FRUIT ST O 586-4450 O NORTHAMPTONMA01060 ISSUED ON.8116104 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE BEDROOM CEILING 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 Occ Qancy Sianature: FeeType• Receipt No: Date Paid: Check No: Amount: Building 8/16/04 0:00:00 1376 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo