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36-136 (3) p¢.�HAMp�o g� tig Cri s of Nart4ainptan L r � � �[assachusrtfs - s DEPARTMENT OF BUILDING INSPECTIONS t INSPECTOR 212 Main Street • Municipal Building Northampton,MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as iris/her construction sups ,,X-or. 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 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 understand the above. (Hom er/resident' �Ature requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date 5 11 Ll I O Address of work location 3T�'l '(71_ lv�er\c-2 , rf\4 oiob�L, r y Gl ifil o �'t7� fl��'t11r}�fnl> z i) j, Ri-?,fEI.rr- OF BUILDING INSPECTIONS 212 Alain Street ' Municipal Building Nlcrthamptoli, Mass. 01060 WORTCER'S CONITENISA'ION INSURANCE A FEDA'V1T �:rit11 a principal place of buslesSelAnce an (phone-';' do hca-cUy CCf-tiIy, l:IlAr dic PAS aiid pcila lt1CS of pCrJll(1t tha', ( ) I am an employer providing the folloWnc `vorkcrs compcnsation `or my employees worizng on Lhis job: (Insara_r1G: Compaq') J c c;Nurnbc-.) ---- (E>:pir.:ion Dztc) ( j I ant a sole provrietor, genera coon c or honlcc%-t ner (circle onel and have hired t.l-,,- COntTactors AM Now who haw the M0 7''g, v oFke-�s Co a°IlS3 i0i1 °''0!= •GS- (N= of ConLnao.r) (T-rls):Ic Datc) (Name of COnirlc<or) b,-r) (lxpi- tin, Date) CName of Contracto-) (IJ71FJ-mcti Dat') (Name of Contractor) — (Ins"Mice Coq; w/Policr Numr-S) (Expi-:iio- Dare) .:7 S li:ltl havc no one 1VOKAn g 101 nlc,. ✓) � ?iIl <'_ 110?�?c (;W?ic. ti:,i-:i.`171ii� ?�1 i'... ',', . ,.: i;i', .;!`t. NO"fT:_plea L,c ewa:c cap{^: ;,o not uK-cc th_n Hiroo umIj ir."55 fm!::,::t"m=T=i:. u'ou'-'--U._..z z '_rtcrs'Lh�r w n.X xrally ccr::c;.:: :o h y a ca*.ploy�urr�rt the tvc:t_n'�cc:'z:^_>_icr.Pr:(GL!52��!(S�,nt:� .__:ic:: . Icgal cta2us of rn emplo}'er un�'c-r t:tn WC�Y[`lt t:on»�•.i.tion:`.cL - I undo.-amd On a copy of 10 ct_t—"A cuy 0 fo""d.d to tl» of Oflj` of i:::,_,ra'r=a for lix covcrggc vaiEctioa and thct f_al rc to c cot-r'r'-c ut d: ct.ia 25.A cf?'(Gl.152 can Im-d io tax imr->i1im of cr i. l PRA:s oomiTIZng of n ftrx of up to S 1.SQO.00 n:r'Jcr i^;�ri ter.�.e:1 of::�to on-}-..:e-.j avil;xststtia in tl�Ic',nn of n$!r.,`,,c;i:(}-u�ar.:i Lra oc S 100.00 1 dty _ Fcc�%�•ssr�zcsl t�.c vtly l / .� - YCTI111t 1`ItllIlfJ'.S _—.------"---'--- 'Y�:i"'�' t t - tr;IllturC or;.ICCII';C' i Si CT.0N 8 CONSTRl1CT10N;SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 1000 KK re"�_:orne:m r vem6fi ontractor.= ; Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10 1N0 RKERS' COMPENSATION"INSURANCE 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...... ❑ 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 acecptable 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. �j Homeowner Signature � - I - ir , r SECT ON 'DES TION1,6VPROPOSED 1NORK(chec t^I applicable) fi t New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors p/ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks L ] SidingW Other [ ] Brief Description of Proposed Work: rro.101616nkl E-Xi3rki n ^ on VN oJS� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll o- Sheet❑ 6a' f 7e in,au"se ri or..a=tldit"i"on to ezistin:hour-Tri corn" 'Ie e� ollow"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 Nc 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 ......Ft�AU�HORIZATION TO BE COMPLETED WHEN OYYNf�SAENT©RCONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize to act or 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. 1 4 , Co 1z' e'-D C Print Name Signatur o wner/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 Frontage Setbacks Front Side L: 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 DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO -DONT KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DONT 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: r 4 t�,of Northampton l► �._ 'tiling Department 3 �12 Main Street x" 204 Room 100 MA ' Y Ploaainpton, MA 01060 5 ' �c -krone 41 -587 1240 Fax 413-587-1272 ` A1sPCICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ,SECTION 1-SITE'INFORMATION 7 Thi be completed by office 1.1 Prouerly Address: Map Ln�E' µ' S PF 01 TAlfe OYerlaj/ V� Dlstl7Ct '" E1117 St.i315trICt C$�ISt17Ct'- SECTION 2-PROPERTY,OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: caaek IL C,k. Name(Print) Current Mailing Address: e oce-nc _ Telephone Sign ture 5 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 b permit applicant �( 1. Building UbU (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) ['CheckNumber This Section For Official Use Ord Building Permit Number: DateIssued Signature: Building Commissioner/Inspector of Buildings Date y 12 LONGVIEW DR BP-2004-1142 GIS#: COMMONWEALTH OF MASSACHUSETTS Map.Block: 36- 136 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-2004-1142 Project# JS-2004-1720 Est. Cost: $4000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 15028.20 Owner: ROBATOR JAMES J&RACHEL L Zoning.URA Applicant: ROBATOR JAMES J & RACHEL L AT. 12 LONGVIEW DR Applicant Address: Phone: Insurance: 12 LONGVIEW DR FLORENCEMA01062 ISSUED ON.5117104 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE SIDING &WINDOW 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 5/17/04 0:00:00 941 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 12 LONGVIEW DR BP-2004-1142 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:36- 136 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-2004-1142 Project# JS-2004-1720 Est.Cost: $4000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sg.ft.): 15028.20 Owner: ROBATOR JAMES J&RACHEL L Zon;,_r:iJRk Aryinl;rnn.*! ROBATOR JAMES J & RACHEL L AT: 12 LONGVIEW DR Applicant Address: Phone: Insurance: 12 LONGVIEW DR FLORENCEMA01062 ISSUED ON.5117104 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE SIDING & WINDOW 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:K THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. , ;r- .�:.�. Certificate of Occu anc si nature: FeeType: Receipt No: Date Paid: Check No: Amount: Building 5/17/04 0:00:00 941 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo