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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 fegulations. 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 r i �O !� oy -= R E (yif t7f �crfllall1 011 A J E -51 assachnsctia' o DEPARTMEINrr OP BUILDr1\C INSPECTION'S 212 Main Strect ' Municipal Duilding Northampton, Mass. 01060 x'10 RJ:CLR'S C O N'LP EN S A'nO N M S URAN CF A FFM A VIT c I ` ',i (lI CCIIS�'Jl)Ct'rnJ IiC�) %vILh a principal place of business/residence at: - _— (+` -N (phone;.') pct S3 -3&`( O ( ci tyfstalc 2ri P) do hereby ceaif;, under thc.pP-ins and penalties of perjury:, --hRI I - ( ) I am an employer providing the followint!workcr's comocasaz ion cove. for my emplovecs worlong on Ll1is job: I , o`s a=Conr.alry) (Potic-r Nu_mbcr) -- ( :pir`tior Dace) j - j ) I am a sole proprietor, geoeral contractor or homeowner (ci c:e one) and have hired the contractors listed below wbo have the follo%ving worker's cao]pen_sation pclIcies: 0"+'1IIlc of Con- Mcior) (II1SilrZilcz- CoInpulyIPouci !-,Iu- l=C:) -- (N:me of Concaaor) (insarancc. ComoaayiPoUn, Nuoiccr) Dale) (Name of Coa=C-16;) (tnsuran<—. Compan)-fPolic)' Numbu) (Cxpim6co Daic) I , I (I`ame of Contrdaor) (tnsuran(-- CompaayfPobcy Nunlbci) (Expir6oa Dail:)- (aIIxh 6ca,irnc _-}'cn mcucc iarormtEoc P=I. aaaz b'u wa--_=o:' ) - I am'a sore proprietor and Gave no one woridDg for me. ( ) I am.-a home o-%voer perforrn-ing all the work myself. NOTE:ple.sc be ewzrc tfi.•-;. le 6cmcowvcrs..vbo employ pcumi en der rgau u-oric oo a d..ell_�of CDC Moto then trrr_=r's is wb�6 the bomoowoc'=da oc ca the ox C-=-By occs:d=-Ci to be cavloycs unc c the..vi dx lion Act(GL'152ss 1(5)�:4plin600 by n bomeoava far c lies__cc permit�y c.id not tLe Ic-gs1 c=3 of na cr.ployx uadcr dip Workoet Co�oa Act t uaZe xaad that a copy a thin cuLcc at a y bo focwwtid d In tba Deputmaat of T,..S.-r.ia Acddc�'OLroo or traur.oe4 ror'b' 00vcra sc vctjf CniOa and that Liliac to so�src toverase under action 25 A of}idL!52 na lad to the iapOS3ioa of eimiasl peairtics ooa3.: of a fiat orup to S 1}00.00 androc 6 p r600mat of up to ooc ycv c.ad aNil pcakja is the focm ora Stop Wort Order aad a Tiro of S 100.00 s ay apuaA aY- f Pcrm)t Numb= lot•a'i �_ Si tare of Lio=scc/Pccmiucc �-� -- j 1 JV SECTION 8-CONSTRUCTION SERVICES t 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone . - Not Applicable ❑ 9: 3e �stered Homelm rctvement Contra'co R C� Com�anv Name -[ Reg' on m er --- -- -`{ w-e-5 V �.�. !Address Expira io Date 4VvA loo„x''� Telephonetf`, SECTION 10=WORKERS'COMPENSATION INSURANCE-- FIDAVIT'(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...... ❑ MW WE 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-vear 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 r SECTION 5--DESCRIPTION OF-PROPOSED''W.ORK(check-all applicable) New House Addition ❑;- Replacement Windows Alteration(s) ❑ Roofing Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[p] Brief Description of Proposed (' Work: Y p�� �C � < o-1 �4 %AJ-R,- Alteration of existing bedroom Yes No Adding new bedroom Yes No . Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet q;.. sa:1€NTew=hotase grad v%ad"cIi#ioo eto xtsfing_fiou"s�na eorn6 of&the- oltcivu1ho 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 AGENT OR CONTRACTOR APPLIES FOR'BUILDING PERMIT 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 I, �v^ {hj.� � _ fctp Qv e t� ' as Owner/Authorized Agent hereby declare that the statements and information on thl foregoing applicatio are true and accurate,to the best of my knowledge and belief. Signed under the pains and penalties of perjury. r 30 L, Print me / � - � /� ©t� ign ure of Owner/Agent Date w Section 4. ZONING All Informatioh 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 l Frontage Setbacks Front s----- Side L:E ' 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 0 DONT KNOW 0 YES 0 IF YES, date issued:, { IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 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 0 NO 0 IF YES, describe size, type and location: j D. Are there any proposed changes to or additions of signs intended for the property? YES 0 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 0 , NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. w y City of Northampton to M1 (( lI r cT1ng Department L � � i ; �4! L�; I''�� Main Street F� koom 100 e N*4mpton; MA 01060 ph4 134 1' 1240 Fax 413-587-1272 H ( 0 e sec ��� �a�� � � � •� _? APPLICATION',T NiTRUCI,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION_1 -SITE INFOR_MATI'N 1.1 Property Address: This sectiort to:00:completed by office zw l�1 S . FMaps Lot � ` Urut Zone Overlaj+Distncf Elm St l)Istnct ;e.,CB Distract SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT' 2.1 Owner of Record: Name(Prin Current Mailing Address: Telephone Signature 2.2 Authorized Agent: l Na (Print) Current Mailing Address: °C 411 ia-i - �6�v Sign ture Telephone Z TION 3-ESTIMATED CONSTRUCTION COSTS' Item Estimated Cost(Dollars)to be Official Use Only com feted 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) Check Number This!Section For Official`Use Onl Date Building Permit Number. Issued: Signature: Building Commissioner/lnspectorof Buildings Date s 1143 BURTS PIT RD BP-2005-0470 GIS#: COMMONWEALTH OF MASSACHUSETTS Ma -Block:36-001 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-2005-0470 Project# IS-2005-0620 Est.Cost: $6360.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Pepin Roofing & Siding Co 107104 Lot Size(sq.Q: 9801.00 Owner: O'DONNELL JOSEPHINE V&MARY Zoning:URA Applicant: Pepin Roofing & Siding Co AT. 1143 BURTS PIT RD Applicant Address: Phone: Insurance: 54 West St (413)527-3640 EAS-FHAMPTONMA01027 ISSUED ON.10/19/04 0:00.00 TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF 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 10/19/04 0:00:00 4404 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo