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29-024 (2) �.e w g'CHN'1p7. O O (rity of Xort4ainp ton L Z � � I�Tassacl�aseffs - r m DEPARTMENT OF BUILDING 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, A t j C A- c—,A- rc 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 7/2, 4_00 Address of work location 4 h�O � z-f �`'cY1-�1jtllll�JfnT1 - 6 ��i!l RCl11i6CII! Z DLPARTMENIT- OF BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 ` W MCER'S COMTENSATION INSURANCE AI �A�nT 1 - ""Ith a principal place. of btlsiness/r<�sidence t: ------- (SiTe�UCIt'i% CIO het-cby ccl—ufti', i!llel - dlc DPlms and pcn ltl'12, 0i i^�f:r�ll(1�, ',1 a" } I am all employer prOvldln the 10110"virlf_ .' OI-tcl"s collinctlsa-1011 CoVera`Ie- i0r II1}' eluplovees `vor�drlg on t-Im job: (InstranG Cotnpam') c-c;Number) --- (r�rirtion Datc) < j I al;-1 a sole proprietor, general c-c)n*cnc`cr hoolto%voer (circle one's and '',avc cured the contractors listed beiovv,�to 'he (N=c of ConLmctor) (Ins race C crnn.;;:?'ctief NurnlYr) iT '; . .icr Datcl (Diane of Contnlctor) � (711sI lace Coy nz.v/PD!ie,' Ntnrrr) (EYT it tips Date) (Name of coanclor) 1DSc at1C^ (.:� '? }'%�OI:C. IvI1II11} r� -- -.ti•; ;:: Q Dat'c) - (Name of Cont-actor) -- (Ins rant Colnrryly!PoLi� ivtu.mti=r) (I;>:r,:-::;o', Date) ( 1 iLTI <i Ole 1 1 C tr l , 1� ..Jri: o t r �l• leCOi <':. ,1 h�IVC [1C� OI .ii`i Or Iilf,. 11iI1 Z1 f: t: SECTfON 8 -CONSTRUCTION SERVICES 779 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder • ti A License Number Address j'�y Expiration Date Signature Telephone �Reg" st°a ed" "omlm'" n�rovemerit Con"tractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10 WORKERS',COMPENSATIQN INSURANCEtAFFIDAVIT(NI:G:L. c. 152, §'25C(6)) ..... �,W .:: 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. r� Homeowner SignatureG2[Cti+GTe z SECT{ON = D S R{LAO't-©'F -eROPOSED 64iK cFreckatl a dcwe New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors Accessory Bldg. ❑ Demolition❑ New Signs [ j Decks [ ] Siding[ ] Other [ ) Brief Description of Proposed Work: L( ��� Alteration of existing bedroom Yes_ No Adding new bedroom Yes X No Attached Narrative 0 Renovating unfinished basement Yes _ No Plans Attached Roll 0 -Sheet❑ 6a 'zip;OM'o 3e.and od:dist onto.x stffighousing�comp�e a he fol�owrn 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? In. 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 . 1. Septic Tank City Sewer Private wel-I City water Supply SEC� 1Q1� �3�INERAUyORIZATION TO 8E COMPLET=ED YVHEN OWf E S�AGE� 70 CONTRACTQR APPLIES°fOR BUILDING PERM't as Owner of the subject property hereby authorize to ac; on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owher Date C G 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 Name,,. � 9 co Signature of Owner/Agent 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 bya.. 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: _.. ............. owl* s� of Northampton t ing Department Main Street 3 om 100 Q 5 Nor t am ton, MA 01060 e- S� phone 7-1 40 Fax 413-587-1272 �f ;. APPL CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATfON z 1.1 Property Address: This s��ect�ontobecom etedby "ffice� �� 1 2C t-f ( � � Map& E .Lo ity �—LC�r2�cV L VS �'- Z Zon Overla. str�- mv t EI t •Distr s� SECTION 2 -'PROPERTY OWNERSHIP./AUTHORIZED AG"ENT 77-7 77 2.1 Owner of Record: Name(Print) Current Matliig Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION-,8-1 ESTI MATED"CONSTRUCTIDN COSTS" 7F Item Estimated Cost(Dollars) to be Official Use"Only completed by ermit applicant 1. Building (a) Building Perm'it Fee 2. Electrical (b) =stimated Total Cost-of Construction from".6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 2 s. 6. Total = (1 + 2 + 3 +.4.+ 5) Crn t,� Check Number 2,$0 .This Section For Official Use,Only Building Permit"Number: Y�"200 Y—62- Date.assued: nature: Q Building Commissioner/Inspector"of Buildings Date t,. HILL; BP-2004-0267 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category - BUILDING PERMIT Permit# BP-2004-0267 Project# ,JS-2004-0389 Est. Cost: $6000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 16204.32 Owner: CARR PATRICIA J Zoning:URA Applicant: CARR PATRICIA J AT. 14 BIRCH HILL RD Applicant Address: Phone: Insurance: 14 BIRCH HILL RD FLORENCEMA01062 ISSUED ON:919103 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 8 WINDOWS AND ONE SLIDER 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 9/9/03 0:00:00 2805 $25.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo