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29-214 (4) i r O' N 1 E 5 I E � r 3 j I D n � D m r .. m e v All m jinn f `: m z <. � z c .� ,t Y •V LT rrgg � R `1 O • s r s� � \ IL IF z c i s 'd A Ju j% o a o � 6 '0 01 a b. A FO bb o02 r BL { I M i „ f0 bb oC N 00 ,001 00 001 � ; 9j M „ FO bb 0 0 N - I Jb •S'Fl I ^ OB j + ,b is 0-90 09 , 0:9 ' C1 E S8 SO co o /per' D N o , .. 9 O * /00. 00 W 4 p 0. 0 — O O I i2.ip yL Q' t,, O i �► .4 r � Q, ,� 0 10) i ':"' r � ! ., . � � f'. 4 �' ., !' n tl f .. .6� #qa y e dr. r * �� �yi�a��"wr r � t ,t: � � •, •,J �F lad, Q CO • �oZ1 A R oo %W O&IIJ4 t17 4zatw4lov r',"d Z&w LE �'t1iA1NP7. of Wort4ampton z �11835ACh1I8ttt4 " 0 m DEPARTMENT OF BUILDIT;G 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 I—is/her construction super,"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 1, 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. Date Address of work location �{ b �LIf1T Tl �it1T1 �?�illl�J [tli : DEPARTMEi.'T OF LUILDD? G INSPECTIONS 212 Mal-11 Street ' Municipal Building Northampton, Mass. 01060 WORTCER'S COMPENSATION INSURANCE &FI'IPAVIT principal place, of busir,esslresdence, ( II nc?=1 (S',TC°UCit r';) CIO hCCCby ccf-uf'• dic pains 'anc pen','It1Cs Oi pf;3�lli}t, :hai_ { I am an emp!ayei' prOVIdi-11, t11 iOl1O'.tiil'!I, v'oI`Kcl`5 collipcim<UoII GOVCrr:vC For Iny elilplovees Wor-Ling tin LhIs job: (Lusdj3IlG ampama) c c:2�'ti lbcr) ----- (Exp;m on Datc) O I am a sole proprietor, gen°ral co-=,cre, or henieO xDc:- (circle one) and ;:ave nireu ln,_ contractors llstct, be.ovi-,V: h� . i Il,' �41i:r - er c! i:_s. n ,: �h� .o_ ., -- v �,orit s co,;.�e�s� �on -,�.�c..,-. (_Name of Contractor) (Ins,=anc�; Co m P 1 c; �r r it cr: Date,) . : ;� o.! uJn � C r) , (Name of Conm,.cor) Coy ra:•,'/Policy Nurlcrr) (Fxc ration Date) (Name of Cclat�clor) (11]$ 'iI:C C:� 1n'i/.�Ol;c. NUJiJI}I� - X, r:i.'Q 1;aI') - (Name of Cont actor) - {Is ra c� Colnrn,v Policy tti`um��) (H--, :1:ion Dare} an) a sole p1-Opric"ui cii!il ha?, f10 OI1 ,'Ur iih t01 I am a home OW?lc' NO•IT:picric be Awz c tl:at•.vLnjc txtr�:y.�;r_ra«ro crap!-,^�, u);:>c--mac:_:;incc,cz:::::.��-_m cr:cpail 111):K c: not itcee th n tluco unifs ir, u a;` ^i sr c;_1 Lhc o-:c n.:<C=xrally ar•::;::c :o t` c�:ployc�uti!�cr 4v rvcci;:Ta ca:y; ;a_icc rs:(G?.!S2.z�!(Sl;.r.!:, ._,.:ir:, v a hoc•iro«•ncr`•c:a Lccu cc p-r::i::: - ....'crcc Its,]flatus of an C=Ployor under thn Wcvker't Co ;ovation?.cL I ur.&-_ztxnd ths:a cvpy of this c;atci-s_•r0-y to of Indi.strinl Atxil tf CIrl w Of for tho . coverage,vaiG(_-1ioo and that E--durc to r vc rnG r u:3; c�.i ^2 SA cf*ml,152 can lrrd to the int)>ositiat oC c'- coamisting of a firr of up to S 1-S00.00 mn 'cr i :;ri r z�_:a1 of::?t�cr.:j- r-.j evil pcmltia in Lr-or S 100.OV a diy for d�;s:unatsl u,c oily ' I Pcrfntt 1 Ji n tturc c)f:.iccn cJl'crmi;tc: _ :. � SECTjON 8 :CONSTRUC f10N SERVICES 8.1 Licensed Construction Supervisor:, Not Applicable 0 V Name of License Holder : � � [1 1 1 S 1 7 13 License Number Cs� �i�5�t� ��� fil t3iti ,,� • 1 f • Loy Addr ExpiratioA Date i • -2-13,71 Signature Telephone 9Reg s ere z�rn mprouement ontracto MR , Not Applicable ❑ Company Name Registration N mber Address Expiration Date Telephone SECTION 10 1NORKERS',COMPENSATION 1NSURANCE-AFFIDAVIT(MG: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...... ❑ 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 _ SECTION_5 `DESGRIPT(ONOF PROPOSED WORK(check all anol�cable� XT New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks 10d. Siding[ ] Other [ ) Brief Description of Proposed Work: 6 &A-L1)-T,L)& , n Y, � jam, Alteration of existing bedroom—Yes--)(— No Adding new bedroom_ Yes No Plans Attached Rolm-Narrative D Renovating unfinished basement Yes No Sheet❑ 6a�:f�(�eSiv�oud�or addation�to-existingttousiang�-comple�e the�"fal,Lowin�: 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 SECTIOPI 7a {3WNER AUTHORIZATION -'TO BE COMPLETED;; WHEN OWPfEftSAGENT O �CONTRACTOR APPLIES,FOR BUILbING PERMIT I v \r{G I N 4\ l-Jtt 1�7`£ as Owner of the subject property hereby authorize to act. on my bed qlf, in all matters relative to work authorized by this building permit application. Signature o wner Date — 11100 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. Pri Qje) Signature of Owner/Agent Date t � 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 �' d L 5� S,�. � Lot Size � Frontage 102 -96 f0 Z • 0 ./ Setbacks Front 2-4 ' "1 '50 Side L: 24 R: 3 0 L: ($ R: 0 /6 j Rear 115' l D b l �(� Building Height ?41 Z Bldg. Square Footage 10-4 % Open Space Footage (Lot area minus bldg&paved l 1 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 V1 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 ere any proposed changes to or additions of signs intended for the property?YES No IF YES, describe size, type and location: s City of Nord Building De6aff-krent e � { 212 Main � et JUL - 7 2004 Room i00 _ � a r Northampton,!;Wk phone 413-587-1240 'Fax 413y587- APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: This sect�o>�x to be completed by office #1hit, vu,, j�'Z-d>2��VCi(� 'Zone'• � ��.. ' overlay=D�str�ct a Elri�ySt.DIstnct :! C8'Dian SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED.AGENT 2.1 Owner of Record: !/'l/; di r��/J/- 7 I ►r1 �A-r��¢- 3 0� � Name(Print) Current Ailing Address: Telephone Signature t 2.2 Authorize 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 / / 0 (a) Building Permit Fee 2. Electrical ,O t G' (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) 0 o Check Number !!11 This Section For Official Use Onl Building Permit Number: .�i�D 5 -' Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2005-0026 APPLICANT/CONTACT PERSON DANIEL HATHAWAY ADDRESS/PHONE 2 OLD GOSHEN RD WILLIAMSBURG (413)268-3135 PROPERTY LOCATION 117 ACREBROOK DR MAP 29 PARCEL 214 001 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 lo 7,777 Z55 Typeof Construction: CONSTRUCT 345 SQ FT REAR DECK New Construction Non Structural interior renovations Addition to Existing Accessory Structure Buildinu Plans Included: Owner/Statement or License 081793 3 sets of Plans/Plot Plan THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO 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 Stree Commission Xt,le0a o 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. 117 ACREBROOK DR BP-2005-0026 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-214 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2005-0026 Project# JS-2005-0031 Est. Cost: $6600.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin DANIEL HATHAWAY 081793 Lot Size(sq.ft.): 17031.96 Owner: WHITE VIRGINIA Zoning:URA Applicant: DANIEL HATHAWAY AT. 117 ACREBROOK DR Applicant Address: Phone: Insurance: 2 OLD :JOSHEN RD (413) 268-3135 WILLIAMSBURGMA01096 ISSUED ON.7112104 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 345 SQ FT REAR DECK 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:H O/- E S ©/C 7- Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: yC $-(o-O Final: Smoke: Final: © 1/ THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy ��� Signature: FeeType: Receipt No: Date Paid: Check No: Amount: Building 7/12/04 0:00:00 1077 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Conunissioner-Anthony Patillo