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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 eegulations. 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 buildinL 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 it ch time as the proper permits and inspections are made C:," understand the above. Home owner resident's signature requesting exemption) ( g I will call to schedule all required building inspections necessary for the building permit issued to me. Date k, \ � Address of work location r c i lwrnT r„ �0 GGC3CJC,0 R E (riff Qf �n� d DEPARTJMENT OP BUILDING INSPPG'T1OIdS i 1 _ 212 Main Strcet - Municipal 13miding Northampton, Mass. 010GO «ORltL.R'S COKPENSATTON L'`ISURAhC)✓ AFFIDAVIT. i - V.,ith a principal place of businessfresidence at: --- - - ty/st=/Z3 p) do hereby certify, under thc.pa_ins and penalties of pc9ury, hai ( ) I am an employer providing the following!wori:cr's cotnocnsaho, Covemge for Iny i emplovecs tivorUng on this job: i i (Las=a ,) Tolicy . t-nab-cr) tT;-ptravor.Dzi`) J ( ) I am a sole proDnetor, general coottactor or homeowner (ci c;e one) and have hued Lhe cono-actors listed below who have the following workers coE-2oerLsaaon policies: I ('Naln: Oi COntmczor) (IRRranc Coinpa 1)-hGUCi ?�tu�1LCT) -- `� ':Jtid:?Oi? Datc) (Namc of Contractor) (Ins rancr- Comoanvi?okv Num6cr) (-Dir;:aon Date) (Name of Coan7ZC14;) (msw-anc:. CompanyfPouc)• ivambzt) (Expiratioo Daic) I (Nzme of Contractor) (Insurance ComcanyfPoUcy Numb`i) (Expiration Datc). (aas[b:6di-oc3!eca,ifncoe_-Y to iaCtud;tafort��oo Pciniains to LU Dom•-r�—:3) - O I am a sole pr-opnetor and have no one worming for me. 1 I am..a home owner performing all the Nvork myself. NOTE:Plesc be ewzrc Lij�wt lc 6cmcowvcr�vlbo cacplay pc-coax co da c.a ccsse oo c rraau work on.d..<n:-;:of not Mott Ib=n Lb=L--Litr is wi ea the bomoa we r=ido or oa the Qo,n xppsrtca z t the oecs:d=-ni to be cixplor--ttac the- -icts C==P .",•oa pct GLIt 52.=1 t (5)).=-PPticjboa by a homeoave fcr c lice_or pezxnit n_y­idmac the Ic J rt».,of na-=Play-oodcr dra Woke.comp._,L oa.pct_ ' . t uad=-iun tba a oopy of thin,mt==oI m.Ly be foa-x ded to tbo Oepn .t t of Indaauid AcedcaiY Office of Inaa—for tb. novel se r cif e�ioa aad thst f iliac w soeurt covernse toaion 23 A of}SQL 152 m tcLd w the"option of eimias!pea&Wcs coosismg ora floc or up to 51300.00 and/or ofuP Lo ooc yror t-ad civil pmJtia in 6c form ofa Stop Wars;Ordcr Lad a fish of 5100.00 1 d_y LpinA tnc u,e Doty — Pczmit Nttmbcr Lot j ignatlnt of L 1 SECTION1-CONSTRUCTION SER\/ICE$ r 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone Seats ereotn mproyementan MEN g Not Applicable ❑ Company Name Registration um er Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE'AFFIDAVR(M:G 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 Massa as s General Laws Annotated,you maybe liable for person(s) you hire to perform work for you under this permit. The undersigned"homeowner"certifies and assumes re onsi li for compliance with the State Building Code,City of Northampton Ordin ces,State ocal Zoning Law and t of Massachusetts General Laws Annotated. *omeowner Signatur t lil r i SECTION'5 DESCRIPTION°OF PROPOSED WORK(check�all applicable)' New House ❑ Addition []:;: Replacement Windows Alterations) ❑ Roofing Or Doors ED ED Accessory Bldg. f4 Demolition ❑ New Signs [0] Decks [Q Siding[O] Other[E3] Brief Work Description of Propose GP 1( Alteration of existing bedroom Yes No Adding new bedroom Yes No . Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet �a�f°I�'ev #�oase�n �' `c�i#'�ar'< oatwts �nc>I�ho stncr.:�com�p ete�the°`� foing: 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'7a-OWNER AUTHORIZATION ,'TO,BE.COMPLETED WHEN OWNERS AGEN-OR CONTRACTOR i41?PLIES:FOR BCJII_DING 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/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 rjury. i Print N — —' ' C' ld'�--�'\C) Sign ure o wnedAgent Date 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 i Frontage # Setbacks Front [�Z ' Side L:= R:= 'L:± 1 R:1� � Rear Building Height Bldg.Square Footage = % Open Space Footage % AO (Lot area minus bldg&paved parking), #of Parking Spaces Fill: I volume,&Location) I i A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 IF YES, date issued:; S IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES f IF YES: enter Book i Page; i and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 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 i NO I 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: i 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 n r NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. f Northampton (� u i g Department I Main Street ��; oom 100 } c F r — 2004 N pti MA 01060 s 1 phone 413 587- 240 Fax 413-587-1272 I ��tir I CP CTIONS - L APliL' ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1.-SITE INFORMATION ` is secUo xta be com a#ed !I fffce 1.1 ProtwtV Address: e-111 IL C !"L h ' o,cerlayDIsfct `r D 1 Cpna t SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2 wner of Record: Li i I C�- Na tint) Current Mailin Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone -T SECTION 3.-ESTIMA b'CONSTRUCTION COSTS Item - Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant Bui 1. Building (a) lding Permit Fee C, C' 2. Electrical -� (0)'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) C-D Check.Number Thi s Section Foy O.fficiai`use Only Date., Building Permit Number lssued: Signature: i Building<Commissioner/Inspector of Buildings Date File#BP-2005-0262 APPLICANT/CONTACT PERSON WILLIS DAVID T&DEBORAH L ADDRESS/PHONE 39 BRIERWOOD DR FLORENCE O 586-2341 O PROPERTY LOCATION 39 BRIERWOOD DR MAP 29 PARCEL 098 001 ZONE URA (OW, THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out is Fee Paid TTypeof Construction: REPLACE 6 X 10 W/8 X 14 SHED New Construction Non Structural interior renovations Addition to Existing Accesso1y Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE F9LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF 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 Co ssion /va/o d Signature of Building Official 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. 39 SAMWOOD DR BP-2005-0262 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:29-098 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-2005-0262 Project# JS-2005-0329 Est.Cost: $2800.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 13982.76 Owner: WILLIS DAVID T&DEBORAH L Zoning:URA/WSP Applicant: WILLIS DAVID T & DEBORAH L AT. 39 BRIERWOOD DR Applicant Address: Phone: Insurance: 39 BRIERWOOD DR O 586-2341 O FLORENCEMA01062 ISSUED ON.919104 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE 6 X 10 W/ 8 X 14 SHED 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 Sienature: FeeType• Receipt No: Date Paid: Check No: Amount: Building 9/9/04 0:00:00 MO $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo