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32C-291 (3) J �� �� . � � �assacl�usetts DEPARTMENT OF BUILDfNTG INSPECTIONS / INSPECTOR '212 Main Street • Municipal Building Northampton,MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CNM 108.3.4 to act as his/her construction sups":vl 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 fanu _ 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 ' understand the above. (Home owner/resident's signature r1kiluesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date x�, Ze 16---- Address of work location r o�Ztw r nTa o IE Pf �\Tarfljzailipjoii A ' f cs.w Chris;rlle' W d DEPARTMENT OP BUILDDIG INSPPC7I01dS - 212 Alain Strcct ' Municipal Building Northampton, Mass. 010G0 V",'ORICCR'S CONUENSA`IL N MSURA-NCF, Al=- r1.1rIT (Ii ccos.^cJpcTm�tfcc) %vith a principal placc of businessfresidence at: ----- -- (phone;') (st�tJci ty/staicJ�p) do hereby certify, under tbe.p?-ins and penalties of perjury:, hal ( ) I am an employer providing the iollowine l%vorkcr's comocnsation coverage for my emplovices worlong on tills job: omsiu-:n=ColzmazV) (Pelie: Nu-mbcr) -- (ap rz on D2j ) ' O I am a sole proprietor, general contractor or homeowner(ci:c:e one) and have hued tree contractors listed below who have the follo�vius worker's coc-3oensa6on policies (l+smc Of Conmici0r) (IRRrranOL CoIno1n)•/PrUc NUMh-_I) tExpinduon D Itc) (Namc of Coomaor) on-,lraocc ComoanwPoUc-; Nluncer) (E.\D ration Date) (Name of Connaao.) (Imsw-a-ncc Compzoy/PoUq- Numb i) (Expimaoo Datc) (Name of Conaaaor) (Insurance Comrarry/Potiey Number) (Expiration Daly), (aaa.C�1 adu�oc�1 rbcct,Yncca._-y to irv-t, t_iarorm-noa pcta-iniag so.0 ccm--co:s) - O I am a sole proprietor and bave no one worldog for me. 1 I am,a home owner performing all the work myself. NOTE:Plesc be GMrC ifi,•K e bC�rA DOTS Kbp C$PIQy pCTQ61[a d7 =...=oa-rrnu work w.dw,11.i.g of nor moci tJ:a r —,j in Ksyeh the bomoowncr raid or ea the Qain a purtea a the a r c we�=,_Uy oe. d-sd to be cixployc�urx-t!x�+uS cts --*;cn Aa(GU152s31(S)� �P(io tioo by:bomcoaoa far a lice-«pertait rz_y ctiid�«tic Ic$-1 ctsaac of ea-=Ployer=der Ii-W,+,e,Cooapom.tiaa AeI_ I uodcsz,ad the a aopy or thi.mtrmmt a y be f --,dad tv the cr L-&&x id Ac dc-AY OIL-or lrv- a ror t6. _ covcrabc veiratioa and Lt-I L•i=c to gca=)covcnz,�c ruder=ajoa 23A or MOL 152 cxo Ictd to the izrxtt Oa of-imioil Pcaa'6c3 o - Wort Ord-aad• - coosi.:mg f a fiae or up b S I SQO.00 artdlor i�ruo®at of up b ooe ye-.r ead a�i1 pm..tio in tSc roan o(a Stop _ rub o(S 100.00 a d_y L&XinA me For dcq.rtm=�u.c od7 " Merril NUML--r - Lot Map SiUnaturcofLi�cc/Pccmiucc � 05 Ce— -- SECTION 8-CONSTRUCTION SERVICES c 81 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9ea>ste�eorriel�isiwr�errrer► a>titFacfe* Not Applicable ❑ Company Name Registration um er ----- Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATIOI4I INSURANCE AFEI©AVFT(M.G:L.c.1'52,-4,25C(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...... ❑ OW Ml 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 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. meowner Signature r SECTION 5­DESCRIPTION OF PROPOSED WORK(check all applicabiel New House [] Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 0 Or Doors D Accessory Bldg. T Demolition ❑ New Signs [0] Decks [M Siding[O] Other[0] F Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No . Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa Cf ei n :ratseadd%# coy a cam." c>Jion �orpfeeti taxi g: 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. Masscheck 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 SECTION Ta-OWNER AUTHORIZATION-TOBE COMPLETED WHEN OWNERS AGENT.OREONT,RAGTOR:APPLIES:FOR L&'DIN'GRPEitMl l 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 Date ignature of Owner/Agent Section 4. ZONING All Informati6h Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size j Frontage ` Setbacks Front r Side L: R:I L R:# --- Rear I I I Building Height Bldg.Square Footage % I Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces i Fill: (volume I&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:! IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book = Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0 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 Q NO 0 IF YES, describe size, type and location: s D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 IF YES, describe size, type and location: i I 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 1 acre? YES r. NO IF YES,then a Northampton Stone Water Management Permit from the DPW is required. tle n City of Nort0ampton e Building Department 212 Main Street a iu �w r4 Room 100 Northampton;"MA 01060 rent phone 413-587-1240 Fax 413-587-1272x' tr►s� �� APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION I.SITE INFORMATION --. 0 ectton to be corn feted byofffce 1.1 Prooertv Addre s: ^) -4-mr , Lot Alnit U N 2, ° a OverfayDtstrrc F SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED.�a`EI�T p 2.1 Owner of Record: ;E�w_M d A # ,4 DE L E tzs Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTIOR 3-ESTIMATED:CONSTRUCTION COSTS Item- Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant Building �o' dv (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=0 +2+3+4+5) Check Number This Section•For Official USe:Onl Date Building PermitNumber. Issued: Signature: i Building Commissioner/Inspector of Buildings- Date File#BP-2005-1295 APPLICANT/CONTACT PERSON ANTOSZ EDWARD&ADELE ADDRESS/PHONE 34 HOCKANUM RD NORTHAMPTON (413)584-0970 Q PROPERTY LOCATION 34 HOCKANUM RD MAP 32C PARCEL 291 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildina Permit Filled out Fee Paid Typeof Construction: REPLACE 9 X 10 SHED New Construction Non Structural interior renovations Addition to Existin Accesso1y Structure Buildinp,Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON IN$ 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 C ssion 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. 34 HOCKANUM RD BP-2005-1295 GIs#: COMMONWEALTH OF MASSACHUSETTS MV:Block: 32C-291 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: BUILDING PERMIT Permit# BP-2005-1295 Project# IS-2005-1728 Est.Cost: $280.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 6185.52 Owner: ANTOSZ EDWARD&ADELE Zoning.URC Applicant: ANTOSZ EDWARD & ADELE AT: 34 HOCKANUM RD Applicant Address: Phone: Insurance: 34 HOCKANUM RD (413) 584-0970 0 NORTHAMPTON MAO 1060 ISSUED ON.6127105 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE 9 X 10 SHED 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 Sisnature: FeeType: Date Paid: Amount: Building 6/27/05 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 34 HOCKANUM RD BP-2005-1295 CIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 32C-291 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: BUILDING PERMIT Permit# BP-2005-1295 Project# IS-2005-1728 Est. Cost: $280.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(s^lc.ft.): 6185.52 Owner: ANTOSZ EDWARD&ADELE Zoning.URC JWItcant. ANTOSZ EDWARD &ADELE AT. 34 HOCKANUM RD Applicant Address: Phone. Insurance: 34 HOCKANUM RD (413) 584-0970 () NORTHAMPTONMA01060 ISSUED ON.6/27/05 0.00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE 9 X 10 SHED 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 PEIRMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupant Sienature• - FeeType• Date Paid: Amount: Building 6/27/05 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo