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29-197 i Y <Lx (rztp of Wort4amptor � � �Glassachnsetfe - DEPARTMENT OF BUILDD\TG 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 has/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 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, understand the above. (Home owner/resid 's sign ture requesting exemption) I will call to schedule all require uilding inspections necessary for the building permit issued to me. Date—5 6)-.T Address of work `) location Z t� v C�LGDK nel ll'e t-L evIz&_ C /�� • � r �•�ttAN/�?. _. ft ^z L)EI'luRTMEN7 OI' BUILDI?yG INSPECTIONS 212 Main Street ' Municipal Duilcling 2,'orthampton, Mass. 01060 WORICER'S COMI TENSATION INSURANCE AFFMANIT ,v th a principal place. of business/r,�-. cnc 2U �%tsP,e�nn.� Z( ?,ve T[. 4vA—c >Q (phone. ';5H -OCAS C�0 1101-Cl?�' CCr'l1I'1`, 11I1:'tl- C11c' i) li]S 2Il� pCilltlC:; <1i pC1�11I�', :hay. ( ) I am an employes providing the follo'.vil g .::orr_cr`s compensation cove.:r:ve for my t iT1plOVCL'S SVOt�lIlt� on dill lob. (Lns�>ranG Cor ny) (relic:Tdumbcr) ---- ("ra:Glr,:uon D2te) ( ') I am a sole propnctor, vener2 C-J:] C Cr ' i honieO%-,�cer (CLrcle One) anG fL1rf G pthe contractors listed beiov,who 1:--.. the G.0m P'o!:cles: (Name of COnLmctor) (lnsu ancc l GrT )`.;7irrGll f T1USIlt i) %.-?'; r2:.C; Datrl (Name of Contrimc)r) _ (1�lsar,_rce Compa;-yipd,)e., Numbcr) (F?:p r iin Dale) Name of Contractor) Late) - (Name of Contractor) —- JnSuUIanec COIL; Y!1'olicf ^ILl C3]-`.d-�Ii]CYt1�f:.:C4...._-_.TI.^ ::�..r.,..-.._ ...'Y:^.a...n. �--....... � -:li.�:<:::�......•� 1 'lull a �;01C 1)f01)T1CtC)i iii11 11llvc 110 OI1C `•`.'i;ri;.iJl�� tOr ?i1C. ]" 7i11 I? 1101110 Cw?1Cr l)Ct-IC1']Illn� all NOTE:pleasc be awzrc t!:s:.t Jc]x-rco.t r 3";.�c p!w;*..^c n >: �_ ^anc�a:.: n rim cr:c,:a r -:is cl!i' not moce th_n d roo units in ui:idt u a; n C,.to un er thr tvcrl; s ar •�>eti'n Pc 6L.!S,)-,s i 511 " 'ic::h; horrva,.rs`cr leszl rl tun of rn=Plo)w under t!-,c Wcvi c%'t :oat;ern 6cn,.CL I undcztand th+!a cmy of t}ia ctatci:crl c:.y I;o fomwtiod to IlY LYjy Lz-re of lsalltri.1 Ac jjd &Llra°of for ilx eovm&c va-i f roc ynd aut U-ur,-to un-k-- ;5 n of MCI-,152 can lui to the imposiUan on,=stmg of a fur-of up to 51-300.00 an--or ir:prxi.Zti,^1 OF 1.2p to crn:} .:-.I civil n-mllja in do Ii,nn of rd e fry of 5109.00 i day irr-iml m:. For d4%utnL'stal u>.e cirt}' i _ IlII t?Y ___ perrnit 21 __� Jt�naturc cif I.icclL:crJ �' � f i SCTONB, C®T7STRUCTION!SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone QXROM-sTe-e m ve fe-n n rac.o x - Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTl 1 � YIfO KERS' COMPENSATION iNSYURANCE AFFIDAVIT(M G:L -c. 152, § 250(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....... ET No...... ❑ i 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"homeowmer"shall submit to the Building Official,on a form acecptable 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, SZnd Local Zoning Laws and State of Massachusetts General Laws Annotated. g Homeowner Si nature t -f 1 � SELT 0 1 - 5. 2�P €ION OF ROPOSED 1Nb:RK check aid la ( cable , ����} i so New House ❑ Addition G?" Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition[] New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: ADO k'aoF Te J55057-11V6- ..5-1rDF eAV'TRy Alteration of existing bedroom Yes v No Adding new bedroom Yes '� No Attached Narrative 0 Renovating unfinished basement Yes ✓ No Plans Attached Roll 0 • Sheet 9' 6a .; Him_ : or ditfl rn-ito ex'is-linger >o—lbg corn "�.E 'hie'! olj �nw 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? wO d. Proposed Square footage of new construction. c © Dimensions—/3/-. ,S X 87. O e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each f g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? h. Type of construction W"©o FWAPIC i. Is construction within 100 ft. of wetlands? Yes ✓ No. Is construction within 100 yr. floodplain Yes ✓ Nc j. Depth of basement or cellar floor below finished grade aPOx 60 k. Will building conform to the Building and Zoning regulations? ✓ Yes No . I. Septic Tank City Sewer ✓ Private well City water Supply NEL) ORIZ'ATIO TO N' BE COMPLETED WHEN OVINE S ONTRAGNMWAPPL'IES FOR BUILDING;PERMIT I' as Owner of the subject property hereby authorize to acs or 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 N "e Signa 're of Owner/Agent-- Date t �4 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 ainStreet V m 100 ktit` r,� Nort ton, MA 01060 f ' A hQr e 5 40 Fax 413-587.1272 AP r CT, LTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1!-SITE INFORMATION 1.1 Proaerty Address: � 'his-zed-i"'�to be' eom D.?, VE � Mn' Zon l`���CY✓GE /�q n 3 EI,rSt D,iStrnct Bemis r ct' .. ' _... SECTION 2-PR,6.PERTY-OWN E R S!HIR UTNORIZED°AGENT 2.1 Owner of Record: I9A1ry 94r�>x isA Name rint) Current Mailing Addres : h Telephone c Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION.>3 - ESTIMATED CONSTRUCTION CO"STS Item Estimated Cost (Dollars)to be Official Use'Onty completed by ermit applicant 1. Building > D U (a) Building Permit Fee 2. Ele crical v U (b) Estimated Total'Cost of 6. Construction.fro,m 5 3. Plumbing �C3 Building Permit Fee 4. Mechanical (HVAC) 0,60 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Number This,SectionFor Official Use Only Building Permit'Num..,e. ��, Date Issued: Signature Building Commissioner%Inspector"of Buildings Date'. z i coo ,4 File#BP-2004-0134 APPLICANT/CONTACT PERSON MONTGOMERY DAVID B&DORIS M ADDRESS/PHONE 20 OVERLOOK DR (413)586-0605 Q PROPERTY LOCATION 20 OVERLOOK DR MAP 29 PARCEL 197 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid ` T_ypeof Construction: CONSTRUCT ROOF OVER SIDE ENTRY DECK 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 FO OWING 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 Street Commission A 2 Signature ofBuilding Offici 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. 20 OVERLOOK DR BP-2004-0134 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29- 197 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: BUILDING PERMIT Permit# BP-2004-0134 Project# JS-2004-0210 Est. Cost: $350.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.ft.): 19732.68 Owner: MONTGOMERY DAVID B &DORIS M Zoning:URA A-pplicant: MONTGOMERY DAVID B & DORIS M A1': 2U 0 VcRLL10K Q Applicant Address: Phone: Insurance: 20 OVERLOOK DR (413) 586-0605 O FLORENCEMA01062 ISSUED ON.-817103 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT ROOF OVER SIDE ENTRY 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: Driveway Final: Final: Final: Rough Frame: C7 �—q- 0 Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: Final: Smoke: Final:pyk THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occu anC Si nature: = x FeeType: Receipt No: Date Paid: Check No: Amount: Building 8/7/03 0:00:00 4419 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo