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29-365 O O G1 of Nort4ainpton $ � jitaesacl�nsrtfe - DEPARTMENT OF BUILDING 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 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 nour), 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/reside '��ir*e!nature requesting exemption) I will call to schedule all req building inspections necessary for the building permit issued to me. Date a�X D Address of work location r r 4VA off' T N/'T ti (ldlfli of C ariljcilllpfoll � 6 jilcssxrflttsrtta ' � --- m L)EPARTMENT OF EUILDTl�G INSPECTIONS 212 Alain Street ' Municipal Building j Northampton, Mass. 01060 WORTCER`S COMTENSA-MN 1TiSURANCE A MAVIT v"I'Lla a prncipal placc of busiresslresidencc do hereby ccI-L.&y LIIIACl- tl1 ' l)??I1 'th t: 7 pl li any an criaployer providing the iollov.'ih: '.:ot-r_cr`s comncnsabon covera�c `or Iny employces working on t?Iis job: (Lns uana Company)m+) cc,Nu ttxr) --- (E x p;r don Date) l j I a -i a sole prooiietor, general c�xlircor c+- hocicowce: (cl,:cle one) acd 'slave hired t.lie contractors lISted bf--iov-, 'to the `O l :Y".P -'-1O hers compensa l on (1:umc of Con[rLCCOr) (Lns�� ncc Ccrrn:;;;;Polic� tlulnLYr) :, . ..;ca Datc)- (Name of Cont?<cto;) 025-'Iramcc: Compza l`lpc-hm' Numb^_r) (l :p tin Date) (Name of Contractor) Jnssummc:� Com—,.a y/Polic Nu-mr,�r)- _,q, lion Date) - -Name of Cont:-actcr) —- (Ins ranee Cotrr y.};r oLicy Numtr r) (Exp -:tio Da[e) (r.tL�Gl=-d"IS::OC:'iI c'::ct;_.._._... 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'K"'.a':�i•.�- ._.... - . .:1:.�:<::::�<:"'I l�f) tLTl sole pm'jme'l)i a-nd have no Oil' a home C\',`?;e` i)C?-t:,`I171I'; all i_.., 'l .. .-., No'TI:1 i lc c be a:.-zrc that".tl!Ic F srco:it s:,c-a c pi ;;>:. - o c'. _:_aacc ara m cr:c;;air«,;i,,^ not tncee t11--n dlr'co uni+u in M:ie+t t!�e LScc e a c n<67ays:12, eaIp10ye:3 un'kr t}r:vcr:r:ec z im Ad(Gl-152_s!(5);, ,ia:try n homco«-xr`or a l ccu cc p-r:"!!: legal etvtuc of nn tha wotkcle Co,Z,xr_-.ticm!.cL I undo ta.nd that s cmt y of this ct.tci. cl rrUy bo to tln of Cirl—of':=""`''''a for Ux covcrttse vc;slic7-lioa turd Ih_t E:uz-c to e-,-trc 1c.icn 2 S oC?,(M.152 can lc--d to ttx imposiLian c;c'.m ir--1 pen'lt:s coorutmg oCa f'rrr_of up to S 1,50U.Q0 n:t&':?r of I!?to nr,:}tom r-.i civil}xrultics in dr I<mn of a S!c;, f re,of S 100A0 a day t'-sin:l _ For&i%uuinrsl u,c c.�:ty I Ycrmit Ntt - ------------- 4 SECTION 8=CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Reg s e e bm mprotrern'ent ontraiaor Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTIONIO 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...... ❑ a 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 fo;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 M ��i3iaL� .4Z#a� �� dd�'F�'y' Y'be gF - v✓ .., - X Yi 31 OOFPROPOSEDJWORK checkgafl a IicailE New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: (fi 0 4 �d_� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative D Renovating unfinished basement Yes No Plans Attached Roll 0 - Sheet D a fMeSnr hfl end oWddi:ti.on� i5t!W t sing comp#e he following 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 SEGTIdT�`l 'OWN�ER�UTIORIZATION TO BE COMPLETED .WHEN O11YNEfSAGE (3� ^� �RGONTFtACTORAPPLI.ES FOR BUILDING PERMIT 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, , 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 G Signature of Owner/Agent Date A� "r 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 Building Department Lot Size Frontage Setbacks Front 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 DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T 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: City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 e 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 1.1 Property Address: This sectio to i� c©mp ete byoff�ce ; a $ � �ZOne Ouerlayb st t- F` EImStDrsfrict arr � B District ."_. d . SECTION.2 - PROPERTY OWNERSHIP/AUTHORIZED-AGENT 2.1 Owner of Record: �- Name(Print) Current Mailing Ad ess: Telephone Signature L7 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTIO'N.3 - ESTIMATED CONSTRUCTI'ON.COSTS. Item Estimated Cost(Dollars) to be Official use Only completed by ermit applicant 1. Building (a) Building Permit Fee c-t9 u 2. Electrical (b) -stimated Total Cost of Construction from0 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number This Section For Official Use Only Building-Permit Numbe..r: Date Issued: Signature: L Building Comm issionWInspector of Buildings Date T BP-2004-0324 G1S#: COMMONWEALTH OF MASSACHUSETTS Dick. 2� 5 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2004-0324 Project# IS-2004-0471 Est.Cost: $800.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq ft.): 17990.28 Owner: HERZOG BRENDA J&WOLF-DETLEV Zoning: URA Applicant:. HERZOG BRENDA I &WOLF-DETLEV AT. 79 AUSTIN CIR Applicant Address: Phone: Insurance: 79 AUSTIN CIR (413) 584-31110 FLORENCEMA01062 ISSUED ON:9122103 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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: Feel e: Receipt No: Date Paid: Check No: Amount: Building 9/22/03 0:00:00 4574 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo