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29-427 (5) ' �{ � Y`. i 1p� 3 { �. I _� _`�, C. � . j y P r � � �. °� �_, r -� ,., ,% ; _ __ __ ,, T �, j,' � `� f` � '� ' mow r,,_� .., �. � �., y —. , ___ .� ,_ � �' .. __ ..: ... i 1 _._. .. ._.. f '{` d./5 I t �_ e .s ..... 1 4� 3 t t '•�. �, � :fie .. ,�. r � __ �. wy Y J ,I�S � ` s i A.i k �� ��1 '�`� 4y� i.. f J r �' ., �� -�� �� _. X30 y G,.,.. �� �rvs�` ^ ' \� V ¢(t1AA1P�. t..Crzr >afzrzlhnitart z $ � �r assxcltusetts 4 � DEPARTMENT OF BUILDrNG INSPECTIONS INSPECTOR '212 Main Street • Municipal Building Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sup ::isor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two famz� - 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 constructian 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, /Yt, 2 understand the above. (Home owner/resident's sfinature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location r I tl. i O O _ � �ZassRrflntrlle' — __ 4 DEPNtTME147 OP BUILDI7\0 INSPECTIO1.rS j 212 Main Street Municipal Budd;ni — Northampton, Mass. 010G0 I «'ORICLIZ'S COil�PENS TION MSURANCF AFFM i.\11-1' I, %1.9th a principal place of business/residence at: -- n U one-J) (sa«t/city/s=/z:ip) do hereby cerdfy, under chc.pains and penalties of penury, =.hat i ( ) I am an employer providing die Following,1, cotnovas_n:Jo, coverage for Illy emplovees worlDng on tliis job: I (Ianlrn=Comp, n r) (Polio:Numbcr) -- (r:-pimz;on Du^.) I . O I am a sole proprietor, gcacral contractor or homeowner (c c:z one) and have hired the coo-aactors lister below wbo have the fobokvmp cac2 nen_s2uon pc!icies: i i (Name Oi Conmlcwr) (Insvranc; Compan)-fP06c; }��llIl1.C:) ?a1FJ On DaIC) I (Name of Contraor) (bi7w-a.ncc Comoaa)vPoLim• \u>ilc_r) (tixpiiz6on Dale) (Name of Coa=107) Omsurane: Compan)-/PoL-q. N:imb�r) (Expimaon Dale) i (i`tame of Concraaor) (Losuran Comrzay/Policy Numb:.r) (Etipim6oa Datz). 'i, (aaat3 ad-ts�ocal�ca,iracccul-to atdudr iaformi-ioo perte;+�to.L oaa-LO:�) O I am a sole proprietor and have no one working for me. 1 I am..a home owner performing all the wort` myself. NOTE:pies:be cwxre lh.:: Se 6emco,,.,,�u•bo caPIQy Peso=W di�m 6- •• r rrpau wark on d.,clL^Z of aoe more then t4av tmf r is u'sch Fbc botaoovvaer rceda a oo the prouaCs s,�yulea rs tbeeo r r ooe V=�r_1y oe,=.d and to he eirployes uaG=the`Ozi is cc=•,=-U- oa A=(GL152-=1(5)},=w U=.6on Iry a bomeoave for c lies_or penart ray aid o=tl:c les-.l rtalac of as e_r.Ployx under dro Work ,Coaxpoayaiion AoL [uadcna-7d�a a oopy of thu mt m-=may be forxnrd.d to the Dip�or 1_6_iJ oin—of t_-v ror the oovea.6-c%crireyoo and Out L-ihae to L0==tovcrase undrs 10e oa 23 A of Mot_1 S2 c=icsd to the imposIIioa of cim;OA pea+liin oo=Ial g of a fine orup to S I X00.00 a &or Lmpj, y of up to ooc yc c.nd a%il pmatia is 6c form of a Stop Wort;Ord=and Gm of S 100.00 a d y aptiaa me _ For&p-=,—_,J u,c only - j / L�c Perm7t NUML--r N'bp° Lot Signature of Lrrniucc e J 1 SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of license Holder License Number Address Expiration Date Signature Telephone 9.Registered Horne Impto-yer t Contractor, Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-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...... ❑ 11. - Home Owner Exemption 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 tag oryner acts as supervisor.CMR 780, Sixth Edition Section 10&3,5.1. M174 ition of Homeowner:Person(s)who own a parcel of land on which hcishc 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 oemn who constructs W2re than ogg home in a two-year pylfod shall not e SQnsidered a h m ow er. Such"Homeowner"shill submit to the Building Official,on a form acceptable to the Building Official,that he/she shall be royonsible for all such wprli ug!formgd under the building permit. As aLlingl Constructioq SupMji or 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'Compensadon) 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 Ordinatnccs,Statc and Local Zoning Laws and Statc of Massachusetts 6encral Laws Annotated. I�Vfiomeowner Signature G i SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoolica�b�b]e) New House D Addition Replacement Windows Alteration(s) [� Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks (M Siding[0] Other[11 Brief Desce'ptio of Proposed Work: Alteration of wdstiL bedroom Yes t/ No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Ba. if New house and or addition to existing housing, complete the followinm a. Use of building:One Family Two Family Other b. Number of rooms in each family unit. Number of Bathroom4_12— � c. Is there a garage attached? (/,' I d. Proposed Square footage of new construction. ;� Dimensions y,/ e. Number of stories? Z I')e- f. Method of heating? L;r j Rrep(aces or Woodstoves ;Z("> Number of each �Z g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction /'u C I i. Is construction within 100 ft.of wetlands? Yes i--/" 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? t Yes No. 1. Septic Tank City Sewer Private well City water Supply SECTION?a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, ,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 as Owner/Authorised 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 Na C ;t ��inature of Owner/Agent Date R 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 Q Building Depai tuent Lot Size 'leil Frotrta e Setbacks Front 30 Side L: R: Rear 2-4 Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved arktn ) C`U #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO O f-MT KNOW YES IF YES,date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON-r KNOW o YES 0 IF YES: enter Book IPage and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES O IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained 0 , Date Issued: C. Do any signs exist on the property? YES NO Ak IF YES, describe size, type and location: 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,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over i acre? YES 0 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton Status of Permit: Department use only Building Department Curb Cut/Driveway Permit 212 Main Street Sewer/Septic Availability Room 100 Water/Well Availability Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans Other Specify APPLICATION TO'CONSTRU&,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Pror►erty Address: This section to be completed by office l tc/�1P j} M$P _ _9__ Lot I ` Unit Zone �� Overlay District Elm St District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 1 � 1,Ir� �tnc� a���,,� �c°�)-S,(��". �� (^c�'��e'�r Chi, �-�•ref7Ct' /��/� Cl«« Name(Pdnt) Current Mailing Address: C -5(Y V, y yl�V V- -c�-,�; Xl ` � z_k,2_r _Telephone Signature 2.2 Au jh2 ftd Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Doftrs)to be Official Use Only completed by ermit applicant 1. Building —;2j (a)Building Permit Fee 5 c C, 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) Check Number This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/inspector of Buildings Date i.Awv . File#BP-2005-0984 APPLICANT/CONTACT PERSON HUYSER DIANE M&PHILIP D ADDRESS/PHONE 79 GOLDEN DR FLORENCE ()584-4484 Q PROPERTY LOCATION 79 GOLDEN DR MAP 29 PARCEL 427 001 ZONE URA 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: CONSTRUCT 9 X 9 ENTRY WAY 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 INFORMATION 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 .� O0 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. 79 GOLDEN DR BP-2005-0984 GIS#: COMMONWEALTH 0 1 MASSACHUSETI'b Mal2:Block:29-427 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2005-0984 Project# IS-2005-1358 Est. Cost:$2750.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq_ft.): 10149.48 Owner: HUYSER DIANE M&PHILIP D Applicant! HUYSER DIANE E M & P_HIL_IP D AT: 79 GOLDEN DR , Applicant Address: Phone: Insurance: 79 GOLDEN DR 0 584-4484 0 FLORENCEMA01062 ISSUED ON.512105 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 9 X 9 ENTRY WAY 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: .�j Ouse# Foundation: #0z' LS © S�` l • p I /22160 -j/ . riveway Final: Final: Final:s/�� ! f' Rough Frame:©,K a � Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: 0 Final: Smoke: Final: K THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATION ='} Certificate of Occupanc Signature• FeeType: Date Paid: Amount: Building 512105 0:00:00 $50.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo