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36-092 y of Northamptan z s �1Y11d35AChliStttB - DEPARTMENT OF BUILDING INSPECTIONS /= INSPECTOR '212 Main Street • Municipal Building Northampton,MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to act as has/her construction sup(:: .-isor. T he state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be,a one or two farm _ 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 buildinz 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 04�1wrnT0 Pf {artl1aiilpfo)) g E �lasaitchnsctla' o DEPARTMENT OF DUILDr\10 INSPPCTt01.'S - 212 Train Strcct ' INfunicipal Building Northampton, Mass. 01000 WORT R's CONIPENSATION >JrsuRA_NCF A� 01 ccus_/pc-rrni acc) «lih a principal place of business residence at: — ---- (phone') (str�.t/c�ty/sta.tcrn p) do hereby certify, under the.pains and penalties of pegury., hai ( ) I am an employer providing the followine''v:•orkcr"s comocnsaoor, cove fm Se for my tail lovecs Nvorldng on this jub: onsu an=Comp_mv) (Polio:?:�aocr) --- (r=:pirzt1or, Duo) ( ) I am a sole proprietor, general contractor or homeowner (c cie one) and have hired the contractors listed below vqbo have the follo inP worker's compe_asaaon parties: cmgmc Oi C0:I,.Mci0r) Gn urancc- Cornoan (-I v:.) 1111C) (Namc of Coau-aaor) (]nsdlrancz ComoanylPo!ic-; \UM6!r) Ei-oirziJon Date) (Name of Cotm-acte,) (Insluanc Compan y/Pone}- Number) (Expir doa Date) (Name of Contractor) (Insurance Compauy/Policy Numbs) kT.xpi-,6oa Date)- (aas.�'l edit ocal>3cd,if acocx.r,-to atcv�inform..zioc P=-t ias to.0 ccC_-_r=rs) . { ) I am a sole proprietor and have no one wonting for me. I am.a home owner perfonum., all the work myself. 7' NOTE:plea be ea ue r v tJa 6emeo, .ba c=ploy pezaoa to L�o cs e�oo c n-au work ca a d­LL-z-za of ant mote tb a L`cc taf�is 11'blch the bomoewacr rcaida a oa the pmuad:3 zppuiiea=the--..o z c o(C=. By a=:d--Cd to Lc eitployc-s uade the., :c=P�oa Acz(GL152s 1(3))•=r^9lin6eo lry a bomcoa-oer fc a lies.:or pewit r=y n i&—tl:e lcgsl rtxena of en-=Ploy. under dto Woctc .Comp..lioa Act - I e ds.a(a Dopy o[thi,mzem�may ba foc�.urded to tba r3cQ„tmooa of In�.s:ricl Aan'r.aII�Off oa oC La.ir.noa rot th. cove vcri ielioa and Uu L-iltac to scm=bOv'c a undue soetioa'13A or h(OL 132 na ind to the itnpc ica of climiast pcW-WI= eoc,i Lea of a rise orup to S 1,300.00 aadror i=xpri_%c�of up to Doc yr_r zod civil pmaltia is be form of a Stop Wort;orde Lod a fim of 5100.00 a day apia-i me - For dcput t u,e onJ7 - — Pcr=t Numb= -Lot.' S rc of ic�sCcfpc cc ON Ue_ SECTION 8-CONSTRUCTION SERVICES J 81 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone Not Applicable ❑ g•,Reaist"er'ed�l�t ome-TriiciGavement;Contiactp �`� Company Name Registration umber ---— Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G L."c 152,§25CM) 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 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 Loca Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature r i SECTION 5 DESCRIPTION OF PROPOSED WORK(check-all-applicable) —T E-1 New House [-� Addition [].- Replacement Windows Alteration(s) 1:1 Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding X] Other[p] nef D scription of Pao os_ed - Work: Alteration of existing bedr m Yes No Adding new bedroom Yes No . Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a If�IVew-<horse°and-at a the fa 46-Whig. 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 1, 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 perjury. Print Name c� pe e' 5 Signat a of Owner/Agent / Date ^' Section 4. ZONING All Informatj6h 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 Frontage Setbacks Front Rear Building Height Bldg.Square Footage Open Space Footage % (Lot area minus bldg&paved of Parking Spaces (volume-&Location) A. Has al Perm it/Varianoo/Findi ever been �suodfor/on the s�a? ' �~\ x�� x�� � N0 �� DON'T KNOW �� �� �� IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? �� NO �� DON'T VV KNO YES IF YES: enter Book Page, and/or Document#: ' �� �� B. Does the site contain obrook, body of water orwetlands? NO v���� DON'T KNOW �_/ YES x�� IF YES, has permit been or need to be obtained from the Conservation Commission? ' Needs tobeobta[omd �-� 0bta�omd �-� Date |ssued. � ^�� �~� ' C. Do any signs exist on the property �� ��� YES x�/ N0 �~� IF YES, describe size, type and location: D. Arethere any proposed changes to or additions of signs intended for the property? YES 0 NO 0 ' IF YES, describe size, type and location: E. Will the construction activity disturb grading,excavation,nr filling)over 1 acre orisd part ofa common plan that will disturb over 1 acre? YES `_^K � NO ���) � |F YES,then a Northampton Storm Water Management Permit from the DPW is required. x City of North,ampton p� BuiLgg Department ��re 'eru V Main Street 5e � �atl� ►►� f � rj° oom 100 afe�e �atla6Ef+ty " r , j� s ! `-`s : No pton; MA 01060wets oStrct�ri,Plans i ri [p OM413 240 Fax 413-587-1272 PtolESt fans t la �tf1Pr.rlpeClf' a k •? F{ 3 '.. , I UCT, LTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE IN This.sectidn td be completed byaffice 1 Property Address: J �2?��e-c Ice� IVtap Lot, Unft © / Zone Overlay Distract Ehn Sf District CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit aEeLant 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 0 ON 6. Total=(1 +2+3+4+5) Check Number This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date ,• 1 837 FLORENCE RD BP-2005-0309 GIs#: COMMONWEALTH OF MASSACHUSETTS a :Block:36-092 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-2005-0309 Project# 35-2005-0402 Est.Cost:$21000.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sa. ft.): 174675.60 Owner: DEMETROPOULOS ROGER,PETER JR zoning SR Applicant: DEMETROPOULOS ROGER, PETER JR AT. 837 FLORENCE RD Applicant Address: Phone: Insurance: 837 FLORENCE RD FLORENCEMA01062 ISSUED ON:9114104 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL SIDING & REPLACEMENT WINDOWS 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: Feel e: Receipt No: Date Paid: Check No: Amount: Building 9/14/04 0:00:00 1224 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo