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29-301 (3) � M p d ; G n t� 0 i el a. C o ," VII ro w 1 VA f _ �{11A1NP1• of Xort4ain pt>an z Z s �I IlASSAC{�IIS[tt6 " DEPARTMENT OF BUILDINIG INSPECTIONS 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 iris/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 the proper permits and inspections are made I, understand the above. (Home owner sident's signature requesting exemption) I will call to schedule 1 required building inspections necessary for the building permit issued to me. Date Address of work location I �LIf1�7 llf �:�1artilaillpfolt . $ 6 a5sacll list 115 _ DEPt J21'h1E?.'-f 01' BUILDING INSPECTIONS 212 ATnin Street ' Tfuaicipal Building Northampton, Afars. 01060 NVORKER'S CONITENSATTON INSURANCE A FU)AVIT vrith a principal place of busmesslr,:sidcncc 1: (SiTC:UC71 do hereby Ccf—uy l!n:':r Lllc pi!115 and of 7f;r�U11', 111i!t. vQ1 an eIIlp Oyer pTVIding the iCllo't'-.'if]f '•:01 t CrS COfI1pC;]S3UOIl GOVCIr:JC tQr ]ny elnptovees working on fulls job: cs0,4 1. 1- 0v v (Las-d nc--�: Company) � ) I a-m a sole proprietor, general (cLcle one-) Pnd "t:a',le faired the contTacG ors hstcd beio 'i„:"o O"i `-O!! 5: (I:QLiIC of CO 1LZ 1CtGi (iR5'C I1C Lvinn: ]ji�0I1L`j T�USIl�ri) ?': "<..%G'D2tCl (Name of ContT?.cro:i (],uu ,ncc Comp,l a!ic NL rnt�- (3 :-:in:}D21e) (Namt of Cantrncior) 1_om'; Ce Num b-r} 1;.`i:CO2 Dat,- (Name of Contrmor) _ (Instliallc Colnrr IyfPoli Nu.rnt..r) (H-::.i-::icn Diic) J I dill a home 0`.V?1C" iiCi?C'II]lIl� 111 NOTE:plcnsc lr aitac tt;s:.il_i}c lr-<-co fir 5 i+ o r.�l y;r.. .;� n:. .__:sancS car r m c :-,?air not•1KYC th_o 0irca um,.3]r.1i'1:!c+1:FY l:r..l^:'.t't/�T..:.:..:9(X cXi ca:ployc5 utl.,c 4r lip:}: .ar T=;a:uc,r (GL!5� s!(Sl;,',:,•l:ca:ic;;by a hntarott for z -- legal etatus of an anployec uoc'.er t;to Wcv�e1�Coi,wr_-.xtson�_cL I undo-ztand ih,_z copy of t}ir<ctatc:s'r_uy bo forxwciod to ci [ytinrt-x>nt of Ir.�>_stri:.l/�.0-�1 1'�Ciric�o of for tix covcrmsc vcr-ifiG.tioo and that failure to t- -c :ct'.ic^25A of M,01.152 can lc--d to 11,impasitiOn<:"c: i:-1 pct=ill:=s cocaiTTLlg of a fur_of up to S I,SG10. 0 as ' r ir:,rr;vr._x: of up to cr. }-s !:.1 civil p czuhies in do form fim of SI00.w a day ag?_in:t m:. Fcr d�;uunzrsl u.c ull}' i I F ... Si�I)It t17rC Of J.ICC:7'}C^�F1CCI71 lift.c, _T.;, Si=CTON8 CO:NSTRIlCT10N SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : L-d 0. '`� � J A-,^'"'-k J C S C)? T-7 a License Number �- ( 1 r s yA Address Expiration Date Signature Telephone r9i Re e: m m,r 'en , ontracto` - Not Applicable ❑ 1 J J T ti,-1 j t'/t k',t e r ,F•• C Company Name Registration Number Address Expiration Date /f' ( 7 Telephone `f(J -� (J SECTION "OrWORKERS' COMPENSATION INSURANCE:AFFIDAVIT(M:G.L..c. 152, 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 4the 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"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 and Local Zoning Laws and State o achusetts General Laws Annotated. Homeowner Signa e i A► , f;E T?I07±1 -I TA[ NM xglnO'R.OSELiWYGRK .check=elf=a lica�le New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing ❑ / Or Doors ❑ Accessory Bldg. ❑ Demolitiono New Signs [ ] Decks [ ] Siding[ ] Other[ ) �►.+,o v i iyz 0 V-i Brief Description of Proposed Work: C o•4-,') �L s;o c Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes ✓— No Plans Attached Roll 0- Sheet O add:iVon to xisIin h uo s�ng.:sc "�rn""�"le, e. e�fii5lfow:tto g: a. Use of building : One Family ✓ Two Family Other b. Number of rooms in each family unit: S_ Number of Bathrooms c. Is there a garage attached? ,%' '--, + A� f�l 5� �� d. Proposed Square footage of new construction. -T w bimensions I r A X e. Number of stories? f. Method of heating? ,�-' / Fireplaces or Woodstoves .i✓ tl'+-- 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 /l No j. Depth of basement or cellar floor below finished grade ,Q k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply ✓� SE,�CTIa� ,�fR ���ORIZA7'lON TO BE COMPLETED WHEN OWNEF� AG�N © ITRACTORAPPLIES FOR BUILDING PERMIT O C_ tD C as Owner of the subject property r hereby authorize ��" ^'^ •�( � S =-`' "v.J .r° S c' 2 to act. on my half, in all mat s relative to work authorized by this building permit application. 4 L � J -3 Sig ture wner Date i, y"' e 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 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 l Building Department Lot Size /J `"/ Frontage Setbacks Front S jr Side L: R: .Z y L: ;L Y R: I Rear < `r Building Height Bldg. Square Footage cfc>D r % Open Space Footage p area minus bldg&paved r7 0 0 ` � r �� � � !D parking) � � arkin b a #of Parking Spaces .� Fill: volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW y� YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW 1�. 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 B ilding Department 12 Main Street Room 100 mpton, MA 01060 phone 413 1240 Fax 413.587-1272 C R. `0', ', PPLh' AT10N TO ERUCT ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING `i Q; ., : SECTI - SITE J:NFORMATION 1.1 Property Address: � EThis s�ecta, #obe mp etee�:Eby ff�c N �•( � � C�. C R e :x.10 0 � �2 ; v' � �Map� g �� t. n�# , ;��,: �'" C-'C •mac �' /Y! �( L% Zone SECTION 2 - PROPERTY OWNERSHIP%AUTHQRIZED;;AGENT 2.1 Owner of Record: 1 A LC) C a ';% � J �C2e /� `l-Jfltt Nam (Print) Curt'; ailing Addre`s�s: U Telephone l Sig lure 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTf0N:3.- ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars) to be Official Use'Only completed by ermit applicant 1. Building (a) Building Permit Fee 2. Elec`.rical (b) �_ timated Total Cost of ' d o <) v Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check number S too This Section For Official Use Only Building Permit Number: ._' Date Issued: l Si,gnatvre: _ t Building CommissionerAnspector of Buildings, Date « w File#BP-2004-0227 APPLICANT/CONTACT PERSON RUNNALS&SONS CONSTRUCTION SERVICES INC ADDRESS/PHONE 34 HOLLY CIRCLE (413)527-9203 PROPERTY LOCATION 430 ACREBROOF DR MAP 29 PARCEL 301 001 ZONE URA/ f�,P THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid C511,5710 Z_�"O- Typeof Construction: REMOVE&REPLACE 14 X 14 DECK,CONSTRUCT 15 X 20 CARPORT New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 078730 3 sets of Plans/Plot Plan THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFF ATION 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 Commission / 1 Signature of Building Officia 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. 430 ACREBROOK DR BP-2004-0227 GIS#: COMMONWEAI . ` )F MASSACHUSETTS Map.Block:29-301 CITY O AZTHAMPTON Lot: -001 Permit: Building Category: BUIL_. NG PERMIT Permit# BP-2004-0227 Project# 35-2004-0329 Est.Cost: $10200.00 Fee: $50.00 PERMISSION IS HER rR . 'ANTED TO: Const. Class: Contractor: 1 . Use Grout: RUNNALS & SON-S CONSTRUC RVICES INC 078730 Lot Size(sq ft.): 11064.24 Owner: LOCOCn_` :\MUEL J&K, A Zoctq'Z:URA Applicant: RUNNP L.S & SONS (_ UCTION SERVICES INC Applicant Address: Phone: Insurance: 34 HOLLY CIRCLE (413): 0 WC EASTHAMPTON MAO 1027 ISSUED ON. TO PERFORH THE FOLLOWING WO'' `::REMOVE F E 14 X 14 DECK, CONSTRUCT 15 X 20 CARPORT POST THIS CARD SO IT IS VISIBLE FROM "" IE STREET Inspector of Plumbing Inspector of Wiring ;_'.2.W. wilding Inspector Underground: Service: :ugs: L} Rough: Rough: se# 'undation: 8h 1 sway Final: �, _C _ 6 Final: Final: ! 710 / > ''Hugh Frame: �� Gas: Fire Department 'replace/Chimney: ,drub! - r.:,_ ,isolation: Final: Smoke: :Hal: THIS PERMIT MAY BE REVOKED BY THE ' ".' F NOI'' '70N UON VIOLATI F '% ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy nature: Si_ 1: _ FeeType: Receipt No: Date .i id: .N'0: Amount: Building 9/4/D? 1'10 $50.00 212 Main Street,Phone(-- ")587-1240,Fax: .-1272 Building Cone i over-Anthony ?