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29-254 (6) O�St1AMP)0 g ti4 f..(rx�� it� �Drz���ll1�7fIIlt • Z $ � �Glassac3tnsetts ` DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR '212 Main Street • Municipil Building 5� 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 super,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 amz - 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 mg department-for the Ciry ofNorthampton-wants-anyperson(s)-who--seek-t-o 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 fegulations. 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/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit - issued-tome. Date Address of work location r F� ti� (rii� of ;arfllallt foil - _ A f g�as.rtr}Ittsrtte• w d DEPARTMEArT OP BUILDr,C INSPPCi101.'s j 212 Main Strcct Nfunicipnl Building I Northampton, Mass. 01060 i WORr=.R'S CONTENSATTON MSUTZANCE AFFID,,lNrrr i I, (h�nsxJpc-r�ni ttax) %frith a principal place of businessfresidence at: — i ! (phone=) do hereby certify, under tlic.p?_ins and penalties of pcgury, h.:jl 1 O I am an employer providing the follo%vine",voricers comocns::oo, covcM^c for my emplovices Nvorldng on tins job: (Polio: ?��-ter) (r:pt DaL ! ( ) I am a sole propr,ctor, general contractor or homeoiVner (title one) znd have hired the conira(nors listed below Gvho h2ve the 5,60owinQ worker's c-omptn—,Pnon pokiest I CNL=: Of Contncior) (IRR tint-c- Coinpan}-/PoUCi i (Namc of Conmcior) (Inssrznc: ComDaativPoties \unc_r) (i apiraon Dale) (Nz.me of Connaao.) (Iasuran= Compan}•/pogo}' mjmb r) (Expirdos Datc) I - (ha.mc of Contractor) ansuranc: Comp;.ny/PoUcy Mumb r) (Eapir-16oa D'=). (.1I�<3:dl�ocal�u�.ifncca,�-y w c�cvcs_iafocz�,�oa pc�a:s�w.!I oo�-_co:�) l O I am'a sore proprietor and have no one working for me. I ( ) I am,a home owner performing all the tivork myself. l NOTE:plea be eveyn tfi'. +tEJc hem ovvcra to fit%pcsons w t1a cs._e.,oc a rgair work w a d..clLg of 1 ont mote th-�L-zoe Lomita is wbicb the bamoowvc raeda or cc the C vun6 xppurteo_=tbeen z•t ox C==Dy oC,=r.d-nd to be eitploycs unC the..ui Lh rr.-.n. =i-icc Ac:(GU452•a I(5)1-ppti=6on by.boa ow=fc_lic---or pewit r-f--id—tl:c Icgar n me of en esployer oodc dao Weekoe,Coot p.omaLioc Act ! [uodca aad tta�a copy of thi.mt®ma m. be Cor-,.erde.d to the i r D•op�orto�J nroa-Ody OM—orLza+r.oce rot th. cov cast vc iGcaioa ad a-'L-ihac w soourc LvvcTaSe tadc soctioa 2.5 A of MOL 151 can led to the impoti6oa or-imins!pca�lsio oom.usixtg of a riot or up to S 1 y00.00.:adfor of up b ooc yc-.r Lod cult pm.ttio itu tic room or.Stop W-,k Ord-.nd fug of SIM00 a d:y apiIIS For�w= �.t use ont7 1 1 PC•rIIltl)`ItSrnIKS map-"-- Lot" Signaaut of Lio=iscc/Pcrmiu= e J ` r SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable 2 Name of License Holder: 4,4�- 0 License Number 103 G l O'KA 1A � __ 7-2 --o-& Address pp Expiration Date C, l�.� a- �5 �Z.�' Sign ture Telephone SrYat re ainempcovetnent�antra o Not Applicable m - -- --- Company Name Registration Numum e��---—�-- Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFF1DAMT 1S2-§25"C(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...... ❑ ,,•- m lam.` l� o-� 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 r f • SECTION 5--DESCRIPTION OPPROPOSEDW.ORK(check'all applicable) New House ❑ Addition ❑: Replacement Windows Alterations) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[0] Other[dj Brief Description of Proposed ��� � � (' ` ,V-,-7 G �<1 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 New ousiran. 02 n A a 9ff :�bbf t1)let+ 0 e a ow>fnct: -- a. Use of building:One Family Y 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 7a-OWNERAUTHORRATION TO_BE COMPLETED:WHEN OWNERS AGENT' CONTRACTOR APPLIES:FOR"Bul,rid PIE it 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/Authorized Agent hereby decl re 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 e Si nature of Owner/Agent Date Section 4. ZONING All Informatioh 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 ` f Frontage [ Setbacks Front Side L: R: L:L--�� RE Rear Building Height Bldg.Square Footage % 1 z Open Space Footage -- % (Lot area minus bldg&paved I ! parking) #of Parking Spaces Fill: i volume,&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES IF YES, date issued:, i IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES IF YES: enter Book Paget and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 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 0 NO 0 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: �3 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 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. of Northampton _66ilding Department 212 Main StreetW Room 100 �G05 Northam ton, MA 01060 phone 413 7687-1+240 Fax 413-587-1272 q - APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION.1-SITE INFORMATION ' 1.1 Property Address: �- This sectron to be complefgtl b office ' ©�V lock d � 5}` f EImSiDistrict C6D�stnct ', SECTION 2--PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(P.nt) Current Mailing Address TelephoneF Sigtfatdre 2.2 Authorized Agent: as Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED'CbNSTRUCTION COSTS Item - Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building a0 (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 Only Building Permit Number' -Date t ed: Signature: r Building Commissioner/Inspectorof Buildings Date '• Y �f x t ijk w-,v 85 OVERLOOK DR BP-2006-0114 G1SN: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-254 CITY OF NORTHAMPTON Lot:-001 Permit: Building Cate— BUILDING--PE IT Permit# 13_P-2006-0114 Proieh# JS-2006-0173 stt Cost..$300000 Fee: $25.00 PERMISSION IS HEREBY GIZANtED TO: Con,t: .lass_ Contractor: License: Use Group:* JAMES POWERS---- 043041 Lot Size(sg.ft.): 1581"2.28 Owner: JAMES POWERS } Awp icutrt_.7AMES:PQWERS AT: 85 OVERLOOK DR Applicant Address: Phone: Insurance: 109 GLENDALE ItD (413) 584-4204 FLORENCEMA01062 ISSUED ON:811105 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF _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: Roughs House# Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chinmey: R,, h: Oil_ Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOYJ,D BY THE CITY O NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND .rLATI S- Certificate Of Oc-cu an `?.naturz: ---- FeeType: Da Le Paid: An>10ulit- Building 8/l/05.0:010:00 $25.00 212 Main Street,Flhooc(413)587-1240,Fax:(4'3)587-1272 Building Corn:�issioner-Anthony Pati1f,