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LY V oy e Glt�) of SNo1:t(ppllptoll a DEPARTMENT OF DUILD[NG INSPE(,T-10,',.,S 2)2, 1vSain SL, ,t- ' Municipal Building SP[CTOR NorlhnmpLon, Mass. 0)OGO Square FooLage AmounL l/ 5 lsc ,:1oDr @ '10 /l S O Iq6 2nd F100,- @ . 20 ------_— 112 Floors, ALLic, Garage . 10 ZY KC) — Dec}:, Porches . 10 TOTLi O��HAMPTD DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municipal Building Northainpton, MA 01060 r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as iris/her construction sup' : :,,,or T!),:, 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 O -y Crztli of Nartilailiptoll z B B ��iSEAChnE[Ila m DEPARTMENT OP BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORICER'S CONITENSATION INSURANCE AFFMAVIT (liccnsccjp;m1ttccc) with a principal place of businesshesidence at. do hereby certisy, under the pains and penalties of perjury, that r I � an employer providing the following "volkcr's comnens�n coverts ge for lily ployees wor ing on this job: (InsusanG Company) (Pe!iCr'Number) p .:lien Date) O I am a sole proprietor, general contractor of homeowner (circle one) and have hired the contractors listed below wlio have the workers compensation policies: (Name of Contractor) Rnsuranc�- Comoany,'Poticy Nusn�--r) Date) (Name of Contractor) (Insurance Cornca:Iv[Po!1c-,' Nurnb--r) (E1:oimnon Date) (Name of Contractor) (Insuranc-c Comi;aoylPokcy Nunair-r) Date) (Name of Conti-actor) (Insurance Comr—=ly/Pohcy Numb2r) (Expir lion Date) (atudt id•!itim>1 s?�.�t tfr.cCCnar. to lo-=1•xs i^�xtniciec:patainir�t.,e11 acs ado:•) i O I it'll it pole proprietor and have no one for ale. O I am a home owner perfonuing all the wor'.: r,i�rself. NMI:plc-_.&c be aw,wc tha;w�:ilc hanco�tizr_t1%+',>o c:nploy t :s to of no(cneee ih_a throe units in tti di he 1>a n vui r reai%-j or ou the g-zt:n.AS zprurter•n+I!K cto ere ex(Scrsally crej:c�-mr :o be c.-11ploy—unlcr the tvoc�;cr's xx __iat m Art(GL152,s 1(5)),nppli_ ticn by a homco%t->r for c hcnu«per u:'n: y legii etaIUZ of an xnployer under tLO WOCiccit Coca>ConLtion Ad_ I undcrstknd di-t a copy of t}iv cut-at¢vy bo forw•nrctod to the L'tj vt­>r of r,.drisirinl Ace&oat Offioo of t:ucru»o for tlw cove"Ec va-diieatioc and that f'Au c to!-tire oovcmgo ur,&r section 25A of hiM,152 can Ir_.d to the imposition of cri ilia 1 pcaslties oomisting of a fine of up to S 4500.00—:9- of up to on:yt and civil pcm)tics in dx foon of a St c-, We Ode.-and a fiac of S 100.0(1 E&y tF&in_st ttvr For dq;utnrs[sl u—only �/�� r� ..l PCTIPlt 1`tllIIltX:� -- - ���� ;.lap:•' - __. Ot — r Sig atuc� of Li cn cJP trait!!- SEC�T�ION��B��C�NST,��tt�,CTION';S.ERVIGES _ 8 1 Licensed Construction Supervisor: Not Applicable ❑p Name of License Holder : `' °��f° �1 ' e G!5 en 1,76/ License Number 3 � r s6 vi��o�� Address Expirati n Date Signat e Telephone = Retr s°p Not Applicable ❑ 6 z Zi/ Company Name Registration Number Address Expiration D to Telephone yC3—S,z7—�3 SECTION�10WO KERS'COMP E ENSATION INSURANC AFFIDAVIT(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...... ❑ mill Oil 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. Homeowner Signature ECTION- D aSUR PTiION�6WO."ROFOSED WORK check 1l a lira le 1 dk 9 mra' W de., +3M lldkS 3t 3 . A `?.'r*'X,vr;" New House ❑ Addition Replacement Windows Alterations) Roofing Or Doors X Accessory Bldg. ❑ Demolitions(' e S' n [ ] Decks [ ] Siding] Other[ ] Brief Description of Proposed Work: COdS tc r7- Alteration of existing bedroom V^ Yes No Adding new bedroom Attached Narrative D Renovating unfinished basement Yes o Plans Attached Rolf - Sheet❑ /h 6g I-f New ho sea d o dclitiWt,%Yi'0ing h uo s-in>fflc'ompae e.tl 'e" foll=,i�: a. Use of building : One Family_� Two Family Other b. Number of rooms in each family unit: 61 Number of Bathrooms c. Is there a garage attached? 6 d. Proposed Square footage o new gonstruction. fCSU Dimensions e. Number of stories? ''z7 f/ f. Method of heating? /3/5/y('t� Fireplaces or Woodstoves �1�4lINumber of each g. Energy Conservation Compliance. / Mascheck Energy Compliance form attached? 4/0 h. Type of construction -2XY 40I'-S i. Is construction within 100 ft. of wetlands? Yes _7V_No. Is construction within 100 yr. floodplain Yes_y__No j. Depth of basement or cellar floor below finished grade T k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer_X Private well City water Supply SECTION 7a� OWNER AUTHORIZATION -TO BE COMPLETED WHEN QWNEFtSAGENTORCONTRACTOR°APPLIES FO R;B Oft DI'NG PERMIT= le'5 /3ag ,/oli/S ! as Owner of the subject property hereby authorize to act on my beh f, in all matters relative to work authorized by this building permit application. U C) Sig a of Owner Date ,t 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. �y c' Print Name Date Signature of OwnepAg 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 V-3 Xcxr 5 y c p O Frontage iF-C) •CSC% Setbacks Front 3C, i i Side L.26 R: 16 L: /Q R: /a r fS Rear 70 7--` 3G5 Building Height Bldg. Square Footage Open Space Footage (Lot area minus bldg&paved ��j y0C /Z� 7 5b parking) 6 6�0 #of Parking Spaces 3 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 7/-5 i 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: x City of Northampton S atus:ofF'et - Building Department 212 Main Street sewer°use; �� alab Room 100 a er t I u- Northampton, MA 01060 pho'ne;41-3-587-1240 Fax 413-587-1272 Plo/S1t , Pin ` AP AAA T4 CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMA-ION ddress: This section to 1.1 Prope rty A be comptetedby office �4' Map` Lot Unit Zon Overlay District G Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Pr t Current Mail nu Address: tv Telephone -- lv�111 S ature 2.2 Authorized Agent: ��� _ �f. �L�s►�rf� � _ �i�.z�fl,! !i4*�/� 5�CJ77S�.9t'1�'Tc-1�✓�/1 Name(Print ' Current Mailing Address: — —yam— -- ------ -- -- Signat e Telephone SECTION 3 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only -_ completed by permit a licant 1. Building 120 b (a) Building Permit Fee 2. Ele .rical (b', stimated Total Cost of -2 Poo, Q© �- Construction from (6) — 3. Plumbing C1c�ca 0 © Building Permit Fee 4. Mechanical (HVAC) 7 5. Fire Protection / 6. Total = (1 + 2 + 3 + 4 + 5) 5-0 C) Check Number This Section For Official Use Only Building Permit Number:_ f Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2003-0971 APPLICANT/CONTACT PERSON JEFFREY CLARK ADDRESS/PHONE 3 KAREN LANE (413)527-8338 PROPERTY LOCATION 17 FOREST GLEN DR MAP 36 PARCEL 019 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid W 70 Typeof Construction: CONSTRUCT ADDITION(FAM RM DINING RM MSTR BATH,SCREEN PORCH), EXP KITCH BEDRM CONVERT CARPORT TO GARAGE New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 076998 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO ATION PRESENTED: _IZApproved 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 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. BP-2003-0971 GIs#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot:-001 Permit: Building Category_ BUILDING PERMIT Permit# BP-2003-0971 Project# JS-2003-1563 Est. Cost: $643.90 6'1 i, s'JJ Fee: $643.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JEFFREY CLARK 076998 Lot Size(sq. ft.): 14679.72 Owner: BARANOWSKI CHARLES W JR Zoning:URA Applicant: JEFFREY CLARK AT. 17 FOREST GLEN DR Applicant Address: Phone: Insurance: 3 KAREN LANE (413) 527-8338 WC SOUTHAMPTONMA01073 ISSUED ON:5116103 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONSTRUCT ADDITION (FAM RM,DINING RM, MSTR BATH,SCREEN PORCH), EXP KITCH, BEDRM, CONVERT CARPORT TO GARAGE 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 5/16/03 0:00:00 231 $643.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo