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36-085 (3) { k +r 't r 3 r: 's ,g �i rt« i �y 1 9 a' ti 5 F 4 cil v �� 4.tKA1y p�, ..Crity of Wart4amptan z Z � � j�lassacltusetts - DEPARTMENT OF BUILDING INSPECTIONS /= INSPECTOR '212 Main Street • Municipd 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 i:is/her construction sup,.:,,6: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 fami� - 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 equired can DELAY the project until such time as the proper permits and inspections are made �- I, �. C understand the above. r me owner/resid s signature requesting exemption) I will call to schedule al required building inspections necessary for the building permit issued to me. Date Address of work location j F E &f of 1LTarf <3111p f011 _ 9 E �la3akcllrrsrtla' ° p DEPARTMEI-T OP BUILDf>\'C INSPECT10111S j 212 Main Strcct ' Municipal Building Northampton, Nfass. 01060 `'orucER'S COWITENSATTON MSURAhCI; AITII A IT" j 010 ns. Pcrmiacc) %V1Lh a principal place of businessfresidencc at: --- --- --- (phone-') (stmt/ci rr lnziclzi P) do hereby certify, under the.pzins and penalties of pcgury, :hat ( ) I am an employer providing the following'workcr's comocnsZtion cove S.c for tn� efnplovecs worlang on ties job: I , (Lan-r=n=Conr,:m') (Pclic:Nu_'-7bcr) -- { :piratiorDzi_-) j O I am a sole proprietor, general contractor or homeowner (ccie one) and have hired the coouactors listed below vqbo }Lave the foUowving worker's cooDen_sa son peLicies: (NSine of COnr;1c-,or) (InRranc:: Comp m)'/Poucy Gale) (Name of Cootrcior) (nstuanec C.omoazwPotic- Ntnc_r) (Ex-Dim-Lion Dale) (Name of Colmaao:) (Insur-anc; Company/PoUcy Numb) (Expirtieo Datc) i i (Name of Conaaaor) (Las uanc-z Comcatry/Pobcy Numbzr) (Expim6oa Date). dditionJ c'sca,if ncc� y w a�cucl iaforw.joo pertninia to.0 ooa7-to.�) j ( ) I am a sole proprietor and have no one woridng for me. I am.-a home owner performing all the work myself. 11 INOTE:plese be ew-art tfi,•..i )c bc,,,=,,,..t,,�P,ay w cU mi c�­= c=—_a.joo c rr ai waric an d..c1La of oat mots thca ttav: tlx bomoot reed.a oa the pvcta zppurtcns=theca Lz not g�.Uy acrd--rcd rn be "Ploy'un'—'—the kai�z�.,� oa Aa(GUI}52x=1(5)}.:ppli=600 by a bomco-=fez a lire.or pr.-mit r>_y the lepl ct vZSC of en a�loyer wader tho Wocti olr Coo�pomriion AeL j !uodcs:aad ttaa a ooPy of t>Zia mtcmcm may bo foc�..vded to tlw p�partmmd of In�ssricl nood�Otrro•oC Ira+rrxa Cori th,. oovexst waif eaioo a-nd th1 L dt:m to soauz)covtra�c uadrs scG oa 25 A of MOL 132 m 1cd to the impos'aioa of criminal pco-Wl 000vsiag of a fine of trip to S I-5oo.00 andfce' of up to ooc ycv e.nd a.i1 penalties in tic form of a Slop Work Order and. fl=o(S 100.00 a d Y a©tinsl rix For ux oaty t GI•mll Numbcr _ 1 ; . - � MMP-"__ Lot { Si curr of Lia=ised ucc e J SECTION 8-CONSTRUCTION SERVICES f, 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9eaisereo npresiremeriiin c Not Applicable ❑ Company Name Registration N— r um e ------ Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION'-'INSURANCE AFFIDAVIT(M. L:c.1'52,•.§250(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...... ❑ 1 � om � V 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"certi and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,State cal Zonin an tate of Massachusetts General Laws Annotated. )Homeowner Signature J SECTION 5-DESCRIPTION OF PROPOSED WORK(check'all applicabie) New House r--J Addition ❑ Replacement Windows Alteration(s) Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks jp Siding[0] Other[p] rief Desc i ti n of Pr o ., /� I Work. /t -;-_- -, C.i,"h Ve& 1 by_ `l lE' '�► D udiC�d�i w;m 42^AC., . Alteration of existing bedroom Yes No Adding new bedroom Yes No . c ry Attached Narrative Renovating unfinished basement Yes No Is s Plans Attached Roll -Sheet 64P am �t*�O' US#"S-°_�n. �""M '-K ei, uuin�; t: 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-OWNERAUTHORIZATION--TO"BE COMPLETED_WHEN OWNERS AGENT:QR C6kTRAC 64iAPPLIES.FORIBUILDWG 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 1, 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. r Print Name �- Sigr6ta+e 6f Owner/Agent Date Section 4. ZONING All Informati6h 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 � i Lot Size Frontage � 1 Setbacks Front _ j Side L:' , R: L: R: s , Rear Building Height Bldg.Square Footage % i 7 Open Space Footage % (Lot area minus bldg&paved i I 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 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 0 Obtained 0 Date Issued: C. Do any signs exist on the property? YES l NO 0 IF YES, describe size, type and location: I D. Are there any proposed changes to or additions of signs intended for the property? YES NO 0 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 r NO I IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton . Building Department e 212 Main Street Room 100 + r.:( Northampton; MA 01060 pone 413-587-1240 Fax 413-587-1272 " - APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This section to be coaapieted by ofl�ce 1.1 Properly Address: f� (��t�5��ct�+'l �''► h-��t.�t� ��Nlap � Lot � .�_ Untt. r 0/0 Elm�t Dlstnct" ....N CB D�stnct SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: Name(!Print) n �/J, ` ,� J Current Mailing Address: S/"IQ1 V �� 1/C-� C.��j l 1C9/I�\/ Telephone Signature 2.2 Authorized Agent: 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 '2. Electrical (b)"Estimated'-Total Cost of 5e Construction from 6 3". Plumbing Building Permit Fee 4. Mechanical(HVAC) of 5. Fire Protection -6. Total=(1 +2+3+4+5) 5700.00 Check Number s(� This Section"For Official Use"Onl Building Permit,Number. Issued: Signature: r i Building Commissioner/Inspector of Buildings Date File#BP-2005-1045 APPLICANT/CONTACT PERSON FAGAN MARY&SHARON ADDRESS/PHONE 211 Westhampton Road FLORENCE (413)587-3340 Q PROPERTY LOCATION 211 WESTHAMPTON RD MAP 36 PARCEL 085 001 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction: CONVERT 1ST FLR BEDROM TO 1/2 BATH/MUDROOM REPLACE WINDOW W/ENTRY DOORSTEPS 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFPRMATION 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 &Z2 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. r 211 WESTHAMPTON RD BP-2005-1045 G1S#: COMMONWEALTH OF MASSACHUSETTS Map:Block:36-085 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2005-1045 Project# IS-2005-0732 Est.Cost: $3500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq_ft.): 30796.92 Owner: FAGAN MARY&SHARON Zoning: SR Applicant: FAGAN MARY & SHARON AT: 211 WESTHAMPTON RD Applicant Address: Phone: Insurance: 211 Westhampton Road (413) 587-3340 O FLORENCEMA01062 ISSUED ON:513105 0:00:00 TO PERFORM THE FOLLOWING WORK.-CONVERT 1ST FLR BEDROM TO 1/2 BATH/MUDROOM, REPLACE WINDOW W/ENTRY DOOR/STEPS 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 Sisnature: FeeType• Date Paid: Amount: Building 5/3/05 0:00:00 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo