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29-358 i 1 (i i 5 v� �4 J 1 f t N t \ � 5 g11AMp�, •�• e Crzf r of &Xort4amptott L r � � ji lassacltusetf¢ -, DEPARTMENT OF BUILDING INSPECTIONS •t INSPECTOR 212 Main Street • Municipal Building ' Northampton, MA 01060 y 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;r,,;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, ceti understand the above. (Home owner/resident's signatu a requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work ll location rT0 a �1-1 ftr .0f 1art 1JaIII 6 f1�[�SACk(Ii6C(tS - D EP/Ji TMEArI' OI' LUILDJI�G INSPECTIONS 212 Main Street ' Municipal BulUng Northampton, Mass. 01060 NVORICETS COMi TENSATION 1NSUIZANCE A.FFMANTIT v:'ith a principal place of businesSlres dente ------- ------------ ---------- -(phone-:;'----- (strec tJci t•:i si�t_:�;•�p) _----- CIO hereby Ceri1IY, 11naG1 III- p::knS i.ii7 pCil ltles 01 pC:rillI}+, 't.Ililt. ( ) I am an employer providing the iollo..itl,_ '.:orKcr`s c0lnhenSatiOn c0verr:ve For lily ealpl0111'ecs Working on this job: (Inm=ca : Corap=,) -- c c:Na nbcr) --- (E-xTiradon D21c) i am a sole prounictor, genera homco«•ne: Ic'cle One) a17C 'tw-, hirtd the contractors listed beio',v-w010 i?2 ,, 'Lilt :L: v;0FkC S COi D°Ilse 01-1 (Ta1iLC Of COntIaCLGr) ins 'aCC l v^I ^]:i'1i1 G!1C{ TJllSIl i) (EX riaiC' Datc)- (i(amt of Cont_nc o:) -- (7.1s�r,_ncc Comp_1�/PG!icr Nts11r) (1=:p .atin, Date) (Name of Coatnctor) x 1 rcc C^, ;2n}iPoj;c. vuls?}xr - , .:Loa ;ate) (Name of C OI,tlaciGr) —- (ICs ana Comr�1}'!Polio Numb-:-r) (fix i :tiar Date) (..^.ILiGt=d�tLcC:zI r:.CCt:...____. :O..n..�... ,...'Y:..i..,n ,- ._.... � ..eli.�:<..:_..__..•i O i Iun a �oic propric��: i`:_iu hav no mlic ..ur �;:� ; 101- inc. dill <'_ I:0?1?e C�'i?1C'� iiCi-.:,`I??lI'��• ?Il i_... '.',, ,., '` .al. i?IVs NO Cfi:please be nna c tlta:.ti�•ilc tr<xo ti:rn%,t-3 cr_.p!^+ n :;_i i1r ancG axccn r m cr:;;a r«•:i: cl!ic not uxre t1Ln(Sono ri+i in uL et he .—z cz:ployc�urx�ss t}x_tw:�;: s cc z--;a:i^r.,+r ((IL152-»!(5):;: . ._anc:;by a k n;aro.vncr:`or n 6ccrc Cr l�gi!nazu�of an a�ployx uadcr tv�Wcvi c.[Con �t;oa z4x�L I undcritxmd that a copy of thi c:atci:s'cry bo fotv+nnjrJ to tIn IYtnrtlx-a of lr,6z trial Az l6—&Ci i of oov=gc vctificalioa and that MOL,152 can Iu1 to tlx pasl::= cv¢-tstmg of A fur_of up to 11-500.00 n:t'.'Y i^::u;.� t :_of up to cr..}, r.=.i civil I cnzi a in do 7i n cf+S!c t'ni.C}Z:�n frm oC S 100.00 a dry[Mina tn_. . for cki=a:uirrtal u.c cttl y Pcrinit Nuultx,r _— ----__ C�i 1)A tutu tar?.ic"r,3 cCJ crm S�CT�ON 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Regs er_ - -ome fmpr vem'en"t�ont acYo � Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SEGTIOIV'10 WORKERS' COMPENSATION INSURANCE.AFFIDAI/IT(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...... ❑ 1 r � 011 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 of Massachusetts General Laws Annotated. Homeowner Signature X �ter�eeL., SECTION ` D SG-R1M OF 08Wki"ORK check all. =..::. -._ ... ''a .t New House ❑ Addition ❑ Replacement Windows Iteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other ( ] Brief Description of Proposed Work:_ X I�. 5 ��e 100 Gb© Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes No / Attached Narrative 0 Renovating unfinished basement Yes ✓ No Plans Attached Roll 0• Sheet 0 6a..hfifi 'eWMA"'u a'hd'o a�ld:itron to ex"rsti'ng-housing comple a fhe fol'lo �nw 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 . I. Septic Tank City Sewer Private well City water Supply S,�ECT�IOI��7a�`0�1NNERA'�UTHORIZATION TO BE COMPLETED VC/HEN OWNEkS/XGENT02CONTRbCTOR gPPLIES FOR-tBUl LDING PERMIT I' as Owner of the subject property hereby authorize AIQ 0 {,A— to ac*,. on my behalf, in all matters relative to work authorized by this^building permit application. Signature of Owner Date I' as Owner/^, 4;"—.-' A,e r�' 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 V Date 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 o- /'-r-0 �� �� Frontage rl� Setbacks Front Side L: R: L: R: Rear 7 y Building Height 8y" Bldg.Square Footage e Y % 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 DONT 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: l., C r, E of Northampton A ding Department -� 12 Main Street !� + AUG 2 3 2004 Room 100 ort mpton, MA 01060 mow. 3-5 7-1240 Fax 413-587-1272 DE!'q QF RJILD� `G I f�^���iiA��orv, a oloso APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION r This section to be completed by office 1.1 Property/Address: / a I i 0/G�'z C Zonelrrerlay District ®[n$ .DIStrICt °CB DIS177Cf SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signs re 2.2 Authorized Accent: dp/16 - Name(Print) Current Mailing Address: Signature Telephone SECTION 3- ESTIMATED CONSTRUCTION?COSTS- Item Estimated Cost(Dollars)to be Official Use Only completed by rmit applicant _ 1. Building cle - (a):Building;Permit Fee 2. Electrical (b)Estimated-Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2+3 +4+ 5) ."f- Check Number This Section For Official Use Only Building Permit Number: D �� Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2005-0212 APPLICANT/CONTACT PERSON NOVOTNY MAUREEN T ADDRESS/PHONE 251 ACREBROOK DR FLORENCE (413)586-1871 Q PROPERTY LOCATION 251 ACREBRO D n MAP 29 PARCEL 358 001 ZONE URA r-7 THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid i Typeof Construction: ERECT 8 X 12 SHED& 10'GAZEBO 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 FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 Co ssion 2 Signature of Official Date Note:Issuance (),'A 'Zoning permit does not relieve a applicant's burden to comply with all zoning requirements acid obtain all required permits from Board of Health,Conservation Commission,Department of public works aua other applicable permit granting authorities. *Variances are ,anted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Dcv,..;,unent for more information. 251 ACREBROOK DR BP-2005-0212 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-358 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Bulldinci DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2005-0212 Project# IS-2005-0261 Est. Cost: $4790.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.ft.): 14069.88 Owner: NOVOTNY MAUREEN T Zoning: URA Applicant: NOVOTNY MAUREEN T AT. 251 ACREBROOK DR Applicant Address: Phone: Insurance: 251 ACREBROOK DR (413) 586-1871 (� FLORENCEMA01062 ISSUED ON:8130104 0:00:00 TO PERFORM THE FOLLOWING WORK.-ERECT 8 X 12 SHED & 10' GAZEBO 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 Sienature: FeeType: Receipt No: Date Paid: Check No: Amount: Building 8/30/04 0:00:00 108 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo