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29-238 (4) o���pTo Crzty of Wart4amptan � � J �IIR'JSRC{�IlSttt6 s DEPARTMENT OF BUILDING 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 sups-„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 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/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 F r a 1 0ililr xif 't7z- lJ�tllt}�fnit 6 {3�[SSR(111i6Ct1D __ DEPARTMENT 01' £UILDI? G INSPECTIONS 212 Main Street ' Municipal Building N'ortliampton, ATass. 01060 r/• WOP`ICER'S CONITENSATION INSURANCE ASM)AV1-T ..���idl a principal place of busir�essJre:,�denec :: YVtA--- C) S:- �- �SiTL':UCitj do liercby cer-Lify, un:1c: t11C ;�, ins .?tld pen:iiie.. O perjllry, :hat: ( ) I am an employer providing the followim, v'.01-r_cr`s compcnS260il covera� c Ior illy employees `for dfig ull t?lls job: _ ( j I am a sole prom-Ittor, gtezl--T c<on.C='Or o- homcotvver ;C;rcle One) and ;:a�.,e hired t.lie cont,-actors i.isteC below .v';o 1:�.-c the fold comply Tl -on tnc ties: (1:QLllC Of COlti'1Ct0i) inc`C .'1G L0IP^:.'it,�Gl1Cj 1J 7Tltri) •T':'::n:ion, Datc� (Namt of Cont?2Cioi) — l,ll7SJ P.GC Coma i�'/PO 1Ci' itI1GC(' (1.sG!7:il0n ll2it) (N'flIIm of CQanctGr) (ILLS 311CL l-O a /1JOl;C: 1 11111) ""j,'I:: OC Daft-) - (Name of Contrlctcr -- r, �, ;I olio Nu.m� ( O-s- r-lice Co z- } rl tIl c. UlC l)rC)pI]Ct Ji iiI11 tic Il0 OI: l;r t/ii`' IOr ii? NOTE:pIc-sc tc atvarc nee¢toee tt-z threo unii in t L*.dt;he 1 -L •.t,-re_:,;=c a; ccr::::::c ca!;)IoYc73 un,:c:the tvc:L::r_cc --•cn :r <- 1r al Rntus of an -_•••, (-�L. �_ '-I:;`'.icaac:`uy s Fntacotcncr`ct-Lcet;c c� 8 amployx unur tho Wockc',C.a^=.vr_-bon I uxi&-=taud th>t a copy of OIL.crate s ray bo fo--�V io;l to t/r D jt tn--,f of In his riel A,,i&sY Ci lc of;:J.r T_a for tlx COv -x3c veriliciioa and that Ellurc to!-sue 25A oI l.1GL.152 cw Ind to tlx imposition o;Cry i::.l pet�L'.0 Comistmg of a fluic of up to S 1-500.00 not for of up to cr.-}: !-.I civil perult;a in do lion of n Str-,`:Jni-0-1=—J lirW a(S10,100 n day I&!dtnl in- . '" rac .uunz.'al ura«ily Pc i / - __ rmlt Nuut�� _ 4 Sig nature ()f ;,iccn _ ^JI)rrnti SECTION 8; CONSTRUCTION SERVICES .:.... 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone -ARegttere-g ' rn marovern'ent ontracto'r Not Applicable ❑ %C 1 J Yv r w co Company Name Registration Number Address Expiration Date 41�11y cw J c., Telephone-�—(?G 7 7/ x-- SECTION 10 WORKERS'COMPENSATION INSURANCE-AFFIDAVIT(M:G.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 acccptable 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 SECTION DESCRION1017 AROPOSED 11V OR K tch ecl all apbl�cable) P�T�t ^ New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: y✓f�uycv .C- Alteration of existing bedroom Yes No Adding new bedroom - Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0 • Sheet 0 6a1fi. ewe o see °ndoradit"ron to ezising::housingcoml:efe the=fol.low�n: 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 SECTION 7a'-OWNER EAU THORIZATION `TO BE COMPLETED;WHEN OWNEHSAGENTOCONTRACTOR 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 as Owner/ iorized Agent' hereby declare that the statements and information on the foregoing application are true and accurate, to the i knowledge and belief. Signed under the pains and penalties of perjury. Print Name Sign re of Ow r/Agen Date 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 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 there any proposed changes to or additions of signs intended for the property ?YES_ No IF YES, describe size, type and location: itj of Northampton �f Building Department "21-2 Main Street Rom 100 T ` Nprthamp n, MA 01060 66o 4l -�587- 0 Fax 413-587-1272 F APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION —7 This,section to be+completed by office 1.1 Property Address � , r `Zane `' Oveirlajr District w Elm St.Distract � °'� '��'" G8 i3istricE SECTION`-"2-PROPERTY-OWNERSHIP%AUTHORIZED AGENT 2.1 Owner of Record: =Srl of or�J � Lt Li.._ Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized` Agent: 1V�cry r it J rr D/!N 6G-IC S! �—c•_ rQ�� `1�11� Name(Print) Current Mailing Address: Sig re 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) o� < Check Number This Section For Official Use Only` Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 11.. - 149 SPRUCE HILL AVE BP-2004-0868 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-238 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-2004-0868 Project# JS-2004-1300 Est. Cost: $2860.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: John Corbett 104000 Lot Size(sq. ft.): 10062.36 Owner: DUMAS DONALD&SHARON A Zoning:URA Applicant: John Corbett AT. 149 SPRUCE HILL AVE Applicant Address: Phone: Insurance: 56 Dimock St (413) 586-8712 LEEDSMA01053 ISSUED ON:3116104 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS 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: Receipt No: Date Paid: Check No: Amount: Building 3/16/04 0:00:00 1841 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo