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29-044 � I »_____, 7M 7 t G � � 4S" 2 C(o y Y ! 1• 1 X �y A w � O , 527 77 97 3'6 12'3 IVZ, Cc 0) E 117 72-44N 527 I iflr of &Wvzf4aiiipfon rr� • 1=1 I�l DEPARTMENT OF BUILDITIG INSPECTIONS INSPECTOR 212 Main Street • Municipal Building -0,4 sV• North,unpton, MA 01060 r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction sup,;: ,-'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/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 ci rt1 u i I I 1011 - `1 q - E ql asaRrhnsrtta' — w o 0EPARTMENT OP BUILDrhG INSPECTIONS 212 Alain Street Municipal Building Northampton, A1ass. OIOGO «VOMCEJI 'S COINEPENSA-MN MSUT_NCI✓ A TMAVIT � (1i perm�ttcc) vVILh a prm_ cipal place of business/residencc at: (phone:') do hereby certifj, under tlic.pzins and penalties of penury, h:l ( ) I am an employer providing the following worker's comocnsarion coven-c for any employees wor�ang on tills job: V (IaEu _.nc Conn) (Pclic:Nt_miyu) -- ' (� :pirtiort Dal--) ( ) I am a sole proprietor, general contractor or homeov' Omer (c c:e one) and have hired the coao-actors lister+ below wbo have the following workers c3 pen_saaon pol}cies: (,Ll;amc Oi Co:u c-'w (In-ur-anc p1rdunr 0:11c) (Name of Coarraaor) ComoazyRoUc-' \umi:,:0 (E.%Dif Lion Date) I (Name of Coamcao. (Lasurdac: Compauy/Pol;-q- Number) (Expimboa Date) (Nzme of Coatrdaor) (Lantrancc Comrauy/Poky Numbu) (E pirtioa Datc). (aIIa�:.ddit orsl t5cd.if nccc3i:1-to iaform_'i oc pcv.iai.as to..11 (� I am a sole proprietor and have no one woridng for me- ( } I am.a home owner perfon-=c all the work myself. NOTE:pig -­be of one mete then _—,j is wbb ch the bomoownrs r=d=or ea Lb.Vvaz S cm:dzod to be c-ployr—uce--Lb--=k='s acrT- -.•ca Act(GLIS2-=I(5)),�;vG aoa by a bomoavc fcr:bcz_a perm+t r=y c'_,& x t1 c lcvj cuzu or as es;31oyw coder dto wockceL coaapomatioa Aa- I t;odeaztaad[he>Dopy of thi.eatemc=a y be fog---d.rd to the poganmoat of Ind++sriat Aersdc.:s 01r+oe or In--for the rbvcrxsc vaiz=lioo a_'fd t!u r:il=to tows`eovcrnbe tinder scetioa 23A of MGL 151 cia lmd to the=PO'aio of e'im ''1 Pea'1 coaziAiag of a floc orup to S 1_Moo arwoc of up to Doc ycr and civil pmahia in ec form or a Stop Wori;Ordcr and a rim of 51 00.00.d_y tptiaA t>K Fot u.c Drily . Permit Number Lot n A signaturc or Li crrniucc 03e j SECTION 8-CONSTRUCTION;SERVICES 8.1 Licensed Construction Supervisor: Not Applicable�❑y Name of License Holder: La ui f 7 /1-ire T®a'` License Number r*-t-a aCOG z- Z 00-7 Address Expiration Da et Y-o z�CP c v Z r)r� o Signature Telephone 9 RearsfeceiiFiorriFnpraieitenf: odtctnc� .a Not Applicable ❑ y Z Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCEAFFIDAWT(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 1083.5.1. 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-DESCRIPTION OF PROPOSED WORK check alt applicable New House ❑ Addition ❑ Replacement Windows Alterations) Roofing ❑ Or Doors M Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[jW] Brief Description of Proposed Work: 416✓tH 2 / Alteration of existing bedroom Yes _No Adding new bedroom Yes v No Attached Narrative Renovating unfinished basement _Yes No Plans Attached Roll -Sheet sa Cf mew fioctse:an�d.© adclit�o'°O eX>FStrrf '".Flou436CII12COM0 a ��ie fa[Our 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. 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 Za,OWNERrAUTHORIZAT10k-TO BE.COMPLETED>WHEN OWNERS AGENT OR.CONTRACTO QPPCIEt�F Ob BUILDING°PERMIT I, t< as Owner of the subject property hereby authorize to act on my behalf,in 11 matters relative to work authorized by this building permit application. Signature of OWnZr Date -� OF CO-(S as Owner uthonze 7anelief.ereby declar hat a tements and information on the foregoing application are tr and accurate,to the best of my ledge - Signed under the pains and penalties of perjury. Print Name Signature of Ow Ag nt Date � wx� |' \6 , v Section 4. ZONING All Information 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 Frontage Setbacks Front Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) ` A. Has a Special ever been issued for/on the site? NO DON7KNOVV KJ YES 0 IF YES, date issued:', IF YES: Was the permit recorded ot the Registry of Deeds? ' NO DON'T KNOW 0 YES IF YES: enter Book Page and/or Document#| ' ' �� �� �� B. Does the site contain u brook, body uf water orwetlands? NO �_/ DON7KNOVV �[� YES �~� IF YES, has a permit been or need to bo obtained from the Conservation Commission? Needs to baobtminmd v~~\ Qbtained «�� Qaum Issued: ' | «�� �~� ' . �� C. Do any signs exist on the propar�? YES �~� NO |F YES, describe size, type and location: D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradiexcavation,or filling)over 1 acre oris it part o�o common plan that will disturb over 1acre? YES ���> NO �0] �� IF YES,then a Northampton Storm Water Management Permit from the DPW is required. .fir �,`m of Northampton `�aiSQ#F'e �. , _� ,� a�-� Il idina Department CurCxCrif?ctuee %� � � � 1.2 Main Street Sewer, -p, 1v Z�Q6 1 Room 100 ateA` JUL 1 � s Northalmpton, MA 01060 wed c In phone 41B-58� 1240 Fax 413-587-1272 P Site F an i_ APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING "SECTION 1--SITE°INFORMATION Thts sectiarx to be completed bar 1.1 Property Address: ofiice v �3 ��at1 PAP_-( RC�U`� Map dot cd Untt �Q C�.'11C�..v �I V C� . Z2ine<* Overfay�l?�stnc� ECn St District C6 Distract SECTION 2-PROPERTY OWNERSHIP/AUTHORIZEDAGENT- 2.1 Owner of Record: Name Current Maili Ad ess: Telephone Signature 2.2 Authorized Agent: Loui6 /",1-1MtCTaA4&" 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 (a)Building Permit Fee /Z aov 2. Electrical (by Estimated Total`Cost of -3i v u `� Construction from 6 3. Plumbing o Building Permit Fee i 4. Mechanical(HVAC) _ 5. Fire Protection 6. Total=0 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number.: Issued: Signature' Z� Old. Building Commissioner/Inspector of Buildings Date a . 4Af loaJ�� r P 1 It n r� J � 1 � 33 PIONEER KNOLLS BP-2007-0071 GIs#: COMMONWEALTH OF MASSACHUSETTS Ma :Block: 29-044 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2007-0071 Project# JS-2007-000115 Est. Cost: $21500.00 Fee: $77.50 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: LOUIS MONTGOMERY 013471 Lot Size(sq.ft.): 11979.00 Owner: PAUL PEGGY A Zoning URA Applicant: LOUIS MONTGOMERY AT. 33 PIONEER KNOLLS Applicant Address: Phone: Insurance: 15 CRESTVIEW DR (413) 584-0256 () FLORENCEMA01062 ISSUED ON.712112006 0:00:00 TO PERFORM THE FOLLOWING WORK.-FINISH BASEMENT (2 BEDROOMS & BATHROOM),INSTALLE=D.-REPLACEMENT WINDOWS & CONVERT BATH RO PANTRY 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: Date Paid: Amount: Building 7/21/2006 0:00:00 $77.503862 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo BP-2007-0071 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2007-0071 Project# JS-2007-0115 Est. Cost: $21500.00 Fee: $77.50 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: LOUIS MONTGOMERY 013471 Lot Size(sq. ft.): 11979.00 Owner: PAUL PEGGY A Zoning URA Applicant: LOUIS MONTGOMERY AT. 33 PIONEER KNOLLS Applicant Address: Phone: Insurance: 15 CRESTVIEW DR (413) 584-0256 O FLORENCEMA01062 ISSUED ON.712112006 0:00:00 TO PERFORM THE FOLLOWING WORK.FINISH BASEMENT (2 BEDROOMS & BATHROOM) 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• Date Paid: Amount: Building 7/21/2006 0:00:00 $77.503862 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo