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29-095 (2) i i J r' rt. r f 1 i t f T r / 'Y� o .r O4�N�pTO litp of Worfjampton L r $ B flats 9 a C4 its r It I "Sill iy 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 !Js/her construction sul : .-;sor. The state defines "Homeowner" as, " Person(s) who owns a parcel on which lie/she resides or intends to be, a one or two family dtivelling, 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 � 7 ` 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 /, / 6itl) Of Tal-filaillpf till RV- 1)E."ARTM,E NT OF DUILDIN(J I I 212 Main Street ' Municipal Bulj(jmi� Northampton, Mass. 01060 NVO P.K E'R'S C 0 M V EN S A T1 0 IN INSURANC)", AFFIDAVIT (io hcichy 'I 21"t pi-ovidin the CI i p!u Cc '2,'01 111v j, I I t II ifo-i Date) sole Elroonc or elleral C')Tlmcto' `,O'n�covvnc "C one) anti have "'Led the contractors 11'sted beiovv -,vho have the fo11-,v,-'-,1-, (-N'pm'c Or Date) T Cu) COIT '1111C of Coi"t:-"'C"ol) have no oil,- fc)l :I-w ilull!" NO TI: he 1t oc that—"py oI Lhi. or 11w 6.nd that 11.1lurc to f�cL-c cOv"%r-ul�kz 25A,-I(MGI,152 n lc_d to tlx c�ullng of 1iM-of up to t") -. ..i civil!'fultj,in t SECTION 8 -,CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone ��_4,aa = Not Applicable ❑ 9 rRerstered Nome I'mprov'ementContractor ,m�.. .._._�< �� a. 4 pP Company Name Registration Jurnber Address Expiration Date SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) r 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...... ❑ 11u: om ® ne ; gemptt60 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-ve rr 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 buildinK permit. As acting Construction Supervisor your presence on the job site will be recluired from time to time, during and upon completion of the work fr.-which this permit is issued. Also be advised that with reference to Chapter 152 (\Vorkers' 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 I aws and State of Massachusetts General Laws Annotated. Homeowner Signature _ __-- --------__. — — r DESCRIto SECTION 5 PTION,,OF:PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. Demolition* New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative ❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet D 5a, If"New.Hdiff °and'or`'addit'ion=to`existing housing,comp`letd"--the.folid ink; 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 AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize aal 1 _ _—__ -_ to ac; on. my behalf �n all matters relive to wo k authorized by this mjilding 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. Signs under the pains and penalties of perjury. Print 1>7e f 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 by Building Department Lot Size / ulJ Frontage f Setbacks Fronts d_ z Side L: 2 3`` R: LS3 R: 3,f Rear Building Height Bldg. Square Footage % iJ(i 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 c_�ntain a brook, body of water or wetlands? NO _ ._ bON'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 E _ 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-♦ .A City_ of Northampton Sat s oPer Buildi-ng Department GurbCut/�D_ 212 Main Street Room 100 Water/Welf3'Val a APR 2 3 2,054ortha'm,pton, MA 01060 Two Sets o Str c urai ans phone 413-587-1 240 Fax 413-587.1272 Rlo SltePans ; APPLICATION TO-CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Prop Address: This section to,be completed by:office is Map Lot Unit - J Z6 Overla Y District' Elm St.District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(P r'� Current Mailhn Address: ieiephone --- Signature 2.2 Authorized Agent: -- ------------ - ----------------- ------ Name(Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item E stimated Cost (Dollars) to be Official Use Only - _ corry_ eted hypermit applicant _ 1. Buildin �7 -g (a) Building Permit Fee s L� (b, tim;:ted Total Cost of - -- --^Kr ' - -� -- - - -- - - Construction from (6) — `-- 3. Plumbing. -- -- - Building Permit Fee �l Mechanic�! ;H'JAr'; � 5. Fire Protection --- ----- ----- 6.—Total - (1 r + ' n_+ 4 + ;� ----- ---- --- Check Number � This Section For Official Use Only Building Permit Number: Date Issued: Signature: - - -- - ------- -- - -- Building Commissioner/Inspector of Buildings Date File#BP-2003-0896 APPLICANT/CONTACT PERSON SMITH PAUL L&THERESA D ADDRESS/PHONE 16 HOLLY CT (413)586-1784 Q PROPERTY LOCATION 16 HOLLY CT MAP 29 PARCEL 095 001 ZONE URA/WSP THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out _ Fee Paid Typeof Construction: REPLACE EXISTING 12 X 20 SHED New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING 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 Commission Signature of Buildin fficial 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. N ' 166 HOLLY Cr BP-2003-0896 GIS#: COMMONWEALTH OF MASSACHUSETTS Ma a,29 .. CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: BUILDING PERMIT Permit# BP-2003-0896 Project# IS-2003-1441 Est.Cost: $1000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sy.ft.): 12980.88 Owner: SMITH PAUL L&THERESA D Zoning:URA/WSP Applicant: SMITH PAUL L &THERESA D AT. 16 HOLLY CT Applicant Address: Phone: Insurance: 16 HOLLY CT (413) 586-1784-0 FLORENCEMA01062 ISSUED ON:4125103 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE EXISTING 12 X 20 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 Signature: FeeTVpe• Receipt No: Date Paid: Check No: Amount: Building 4/25/03 0:00:00 148 $25.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo