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ENERGY CONSERVATION APPLICATION FORM FOR
LOW-RISE RESIDENTIAL NEW CONSTRUCTION AND ADDIT(ONS
780 PMR Appendix J{_-ff�ctive 3/1/98)
r
pppli�nt name: ✓ �� l�il
site mdress.
P.ppl,Urntlddrrhss: �� ff�fl�'1���tLi�-!_i,�%- Cttylitrvn: --_---
f Use Group:
0 Date of r-.00l,cal,10n:
0.nnlirrnt Pf,r.l.�; Y�� hJ2 V�23 � •^,vv;;:-oily� J;;;i,o,i[io: -?./'1
Carnf+-ECnrPoe Pwth (cNtcc o—)::
L Frascriptive Pacl,ge ('_imilec to 1- or 2- family wood freme tuilding; heated -1111A fOSSO fiefs Only
Package (A throuZh KK from Table J5.2. tb) _ Heating Degree Days (HDD6S)fTom Table J5.2 la:
(ror fierns d. through i., fill in afl values lylat apply from Table J5.2)
a. Gross 'WaH k" sq. it t. ` z l R=Yafvc E�
b. Glazine Area" sq. ft :'a;cx
n. `Ic ; R K-
c. Giezine (1tYJ x b+a} C h. 1?asement wall
d Glaz±no l I-vzt h- �ZiaU Porimeiar K
e. %o+ling Rt zlue $ i Hez-one AFtJE _
I r7 C J--, ,m , Peeforr)2nce: 'Manual Trade Crf>' (Limited to wood or metal framed building✓ only)
Dirnal�-_Zo+°re(from, Figure u6-2.2) ❑ Zone 12 ❑ ;gone :S Zone --,4
Att2ch Trail°-Off ir', `2et trom nppEnu'i> 1,(2nd H AC TrcDe-07f W,-onhee+, if applic2bJc)
�j tAA5rheck Softwart
Attach Campii'j Cc e A'eporf and Inspeclion CAe k/isf printouts.
E1 3 Sy3itms Anaiysis 013 ;.nerg-j 5e+ ces
Attach Mars Registered Architect or Engin--r Ana!,vsis
r//A LTERNATIVE FOR A.DD1TUONS ONLY;
a. Gross Wall + �ili•n° .fez -7� t7 sq fl. b Glazing RrEa'' 1 % sq.tt c- Glaziag (100 x b,•a) �
ADDiT10hi v,irh Glazing % (c.)up to 4.may use 780 CMR Table J1 :.2.3.1 below_
k+.NClA4LR!U-talt-_ Minim, Urn R VaSurs
genes#ration Corfir2a Wali l Firor Bastme-it Wall Slav Perimeter. Dep � -°�-
O.39 R-37 R 13 ' R.19 R-10 I R-10,t ft.
❑ -S1JNP1JOM- addition (greater than 40%glazing-to wall and ccihnp gross area) l�;!
Attach "Cnnsumer Jnfwmation Fcrrrrn- from 7$J CM?AppI _ndir B- ZA01,
OftlCial'S N2 me: Cr iciaVs Signature:
Appticztian Approved [] Denied n Date of P.p,-xo:'a!,Denial:
°Gas;,;(S)-1u; D:nia;: (prvride additional details as needed on back side)
_:GLsnvL_tea.-�3'.-bc-dx�uu°l�ooE}�C�ec:rnE or Una I�mcruoa:.
4'SH/J'fP�.
,.Crify of Wart4aimptcm Z
�1 834ALh124[tt4 • -
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` DEPARTMENT OF BUILDITIG INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building '>e
North=pton, MA 01060 'M 5
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as i:is/her construction sup,;:.? sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be,a one orbvo fiW_U y -
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 buil tng department for the City oTNorthampton 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 bac!i l),
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
V/11 -�� �� �tio�i-S understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued-to me -
IDate
Address of work
location
�. :✓r Inn J 1 C:0
0 0
Crib of �.�>ZZ-ff alit foti _
R £ �Z c�akrhatrua•
o DEPARTME1Nr—I OP BUILDr)\C INSPECTIOI.'S
j 212 Alain Strcet ' Municipal Budding
NorthampLon, Miles. 01000
I
w0P-=IZ'S ConfpEl NSATTON ONSU -4 NCF Al'I'IJ)AV'I7'
i
i .
%1.11 tll a principal place of business/residcnc- at: --
(phone )
(s�-�.t/ci rp/sZa.lLra p)
I
do hereby certif)--, under Lhe.p?lnt and pen2l6es of per3ury, thai
{ ( ) I an ac employer providing the following iworkcr's comocasa:Jon coverage nor Illy
elvplovices wor!Dng on Lies job:
(I= r-.:-nc Con^^mil) (Potic:Nu--u!�cr) (-xpirnor. D2=)
O I zn a sole proprietor, general contractor or homeowner ( de one) an- d have hired
the couTactors bs e, below who have the follov, i p worker's co�oen_ ion poLicies:
of Con mao-) (In- rant::. Company/robe, '-,`um c:) Date)
(Namc of Conc-zczor) (Lnsarancc CompaativPo!ic� Ntsnc_r) (! ipirdon Datc)
I
(Na-Me of Co=cio,-) (Insurance. Com-any/PoUcy Nwnbs) (Expir=doo Datc)
I -
I �7��,���
(Name of Contractor) (Insuranc- Comrzny/Policy Numbr) (-xpi z6oa Dat.c).
(an�<��i�oc�l�c.ifnceei_-ti-w induce iaforai'ion pe�i�to.LI ooc-��:�)
I -
I
O I.2-M_a sole-proprietor and have no one worming for me.
1 I am.-a home owner performing all the Nvork myself.
I NOTE:p(csc be zw2rt rfi••v��}c be�o.�vcn uto flay P=-:.c= �=io do a a= c=--z=oo c reuu.cric on a d%,c[L-z of
f ant morn tb_L�nr�r�is��se�cbc bomoo9wc rnida«oo the VMUM ,z7p��the= z ox C=�--lly 0'. 6--'Dd to be
{� cnPlcy=um?---ttx—O- �.,.,�- 'oa Aa(GL!152s t(S)),=-pplin6on by a bommaa=fc e Gam:or pc-mit=-r cvid� Ebc
I`FJ a of en-=?ioy.r reader dxo Warf cic Coespomatipa tier
I
I Sd tha a o ca.t®rm
j O°PY f th;- ov y be w the Dop�of lndu,-..ria!tiecd�.�'Offioo of Ira.+nneo for th.
COQ' �iGc=ioo`nd i1tzc ta'rat:c tovcrree uadc sociioa 25A of l.(QL 157 on led to the izPasitioa of aimi-I Pcc--LWc
oomiaag oC a fine of up to S 1 SOO.00 an&c)c of up to ooc y-=-end aril Pcznt-.ie tin be form of.Stop wwt Ord=and a
j fim o(SIOO.00 a d--y cF,aiaa CD� >
For dy.. � .t u.c ont7
Permit Number — -
b t,{ap° Lot
iSignatitrc of Li�sc-Jpermiu e
SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9:3te tsfere lomem rovemerrtcntracto, Not Applicable ❑
Company Name Registration Num eu�r
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION'1NSURANCE.AFFIDAYIT(M.G.L. 162,;g 25gq
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...... ❑
... m �vegem fill
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-vear 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 d-�Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature_,,
r
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) rW Roofing
Or Doors T—
Accessory Bldg. ❑ Demolition New Signs [0] Decks Siding[l!03 Other[C>]
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'If:Neiiuhouse�'ri °�"ril"ci#ia�isto exist ncto�stnci" -coixit �e�#he-�foiiewi a:
a. Use of building:One Family Two Family Other
b. Number of rooms in each fami y unit: Number of Bathrooms
c. Is there a garage attached? %I /
d. Proposed Square footage of new construction. Dimensipns (l7
e. Number of stories?
f. Method of heating? �`�`� - Fir, eplaces 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
f
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-OWNERAUTHORIZATION.-TO BE COMPLETED WHEN
OWNERS AGENTOR CONTRACTOR APPLIES".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 pal ins and penalties of perjury.
Print Name
Signature of Owner/Agent Date
Section 4. ZONING All Informatibit 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 —
Frontage
,,Setbacks Front y– -
Side L R: L: R:�
Rear
am
d,_t.. 110 �F
Building Height
Bldg.Square Footage ; -Y°_� 0/ /-a
0
Open Space Footage % o
(Lot area minus bldg&paved U
parking)
#of Parking Spaces
Fill: f
(volume'&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO /17N DON'T KNOW Q YES 0
IF YES, date issued:':
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page, and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO V) DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained t 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: �$
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 Storm Water Management Permit from the DPW is required.
�'° De'arfinetit use only
r ,
-- _, City of Nortl;lampton
Building Department b r
212 Main Street
Ee Room 100
2
S 2005 'l Northampton; MA 01060
phone 413-587-1240 Fax 413-587-1272 to i
APPLIEAT6(TO C NSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: a: This section Zo 6e completed by;office
zQf�e Qverlay Dtstr(ct
w�E1mSt Dastnct ' . CB.Distnct
SECTION 2-'PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name—(Print) Current Mailing Address:
Telephone
Signature I
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3--ESTIMATED'CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building / ,/'(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) Check Number kd!y 40—L
- This Section For Official'Use Only
Date
Building Permit Number. 'Issued:
Signature: r
i
Building Commissioner/Inspector of Buildings Date
File#BP-2006-0282
APPLICANT/CONTACT PERSON LEWIS DORA&JAMES NASH
ADDRESS/PHONE 18 MONTVIEW AVE NORTHAMPTON ()582-0637()
PROPERTY LOCATION 18 MONTVIEW AVE
MAP 32C PARCEL 283 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid
Typeof Construction: DEMOLISH 2]TORCHES,RENO MUDROOM CONSTRUCT 350 SO FT FAM RM&
700 SO FT PORCH
New Construction
Non Structural interior renovations
Addition to Existin
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
INFO ATION PRESENTED:
pproved 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 Commissio
� d
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.
18 MONTVIEW AVE BP-2006-0282
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C"283 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2006-0282
Project# JS-2006-0409
Est.Cost: $70000.00
Fee: $315.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 172497.60 Owner: LEWIS DORA&JAMES NASH
Zoning.URC Applicant. LEWIS DORA & JAMES NASH
AT. 18 MONTVIEW AVE
Applicant Address: Phone: Insurance:
18 MONTVIEW AVE O 582-0637 O
NORTHAMPTON MAO 1060 ISSUED ON.912312005 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMOLISH 2 PORCHES, RENO MUDROOM,
CONSTRUCT 350 SQ FT FAM RM & 700 SQ FT PORCH
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:
FeeType: I Date Paid: Amount:
Building 9/23/2005 0:00:00 $315.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo