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36-143 s , E ' � - 1 t ,1 1 tool S! J.- 7 71 In 1 . L 1 1;. OJ t 77� r p t I Y Y y V i ............. ... .......... Z°y .... ..... .. 4:71 IU All 1 i 1..1 i U y � t ' � y of Xort4aiiipto n L A ass a chilli efts i CAF\t DEPARTMENT OF BUILDING INSPECTIONS /= INSPECTOR 212 Main Street • Municipal Building '>a ~ Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as has/her construction sups:-, 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 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, KA 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 f7 cv e e/ KA A- w A"� 6 ��[?SACti 115(IIS z m DEPARTMEArr OF BUILDING INSPECTIONS 212 Maill Street ' Municipal Building 1,,Torthamptoll, Moss. 01060 WORKER'S COMTENSATXON INSURANCE ,-FFMAVIT princlp-d place of bus, esslr sidence --------------- ------------------------------- CIO ilerErJ}` Gel—uj}. L1Il;t i hc' j)<_:•S]$ .'.li� pCil?it1 S Oi O I am an employer providing the follovvint_ % of r_cr`s compensation For my employees wor4dng on this job: v (Instran= Company) c c;Nannbcr) -- (.).7ir.:tion Datc) ( ) I am a sole proprietor, gentrai c::)n*E-M(7ror Inonllcol.vne: (cl cle oat) and aavt hired the contractors listed below ,:l o 1: the :oil v orkers c'.0mm nos 01-1 (1`+=c of Conti cu)r) (I E),:--nc D-tc)Y (Name of Contmeto-) _ O:Ls-lr nc Co a:�/Pe!icr \t rntr r) (1 : r.o Daic) (1N13II1 Of O 1ti3Ct0i) — (LI1SI °i1C� l_O y '?il.i%tO11C, T�L1SI?1}`I) _i1 ri.' Dal,-,) - (Name of Contractor) —- (InsZ rand Coax olie ttum�r) (E.:ri�aie : Date) t 1 -uli I'. ,;olc 1)1 opllcLJi 2i1 1 it :''.' no oll i:: iieL for Iilf N07 fi:plcasc tc nu1 c tl:>:.t n7c fxtrco ,r -�r p!'ry _: t :� nt a::.n m cr: ,:ait .... not uKcc th_n th-ce uuiu in tc-Lei ::z oc; clployca un cr t}r TwtLxfs cc z icr.;s (GLL`2 -!(S±).e+: ._ :ir_;;by n hntam. xs`os e ccx cr pc::•..,. . '.. Icgal rlatun of an tl_n Wcvkcic o r-;oration .cL 1 understand dist a cmy of qli-ctstc:cJ r,vy bo fo a nrci J to tiro D:Si L d of Inez riJ A Lira t�Ci i v<f is for Llx covcr-&&c waif-ctlioo rnd th_t flulure to!"n'= un,&--z 25!k of McL 152 can tc:d W ttte im�asitial of r^i:-!paal%. comistmg of a fim,of up to S 1_SCG.o'J a:t=`nr i :;trir;rZ c:Il o( to Cr.:}c`r r.-.j civil Ixruttics in t4 fi r n cf a S!r,`;Y`c k.nti=_r,:I firm of!;100.00 a dsy igain:t m- For d p% txr— j uac qtly 1 1llIltx.=r Pcrinit N 0 "✓ti....� "CJL4 T; F _ t�naturc cif i.iccn�;c:JI'crnr,ttc�:. ': -.- 51=CTION 8 .CONSTRUCTIQN SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone ' Res °e° iebrn' 1m'nxoYem ntTC� r � d'' Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10 1NORKERS' COMPENSATION INSU,RAN-EAFFIDAVIT(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)fami!ies 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"homeo-,vner" 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 buildinZ 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 SECTION = DIES R M ON OF PdROPOSED bRK check ail a hcable New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: X 8, Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes _ ✓No Attached Narrative D Renovating unfinished basement —.L,/ Yes No Plans Attached Roll D- Sheet bat°fiI:evrous `dor ad'dFtion.°aoersting:=housi'ng, completefhe�YfoClow�n : 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. V 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 No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . 1. Septic Tank City Sewer Private well City water Supply SECTIOhCaOWNERAUTHORIZATION TO'BECOMPLETED WHEN OWNtF�S"AGEVTORCONTRACTOR APPLIES FOR BUILDING PERMIT I. as Owner of the subject property hereby authorize to acs 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 �4 Signature of Owner/Agent / Date a 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 i Lot Size 155 113 Frontage Setbacks Front 1 p 3' Side L:I H4.6 R: l ly -•�4 r L: R: Rear j[ 1 C� Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved arkin ) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/variance/Finding ever been issued for/on the site? NO t/ 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: City of Northampton � ' , � p Building DepartmentT 212 Main Street Room 100 Northampton, MA 01060 :� Gt t2-TnF T j^ phone 413-587-1240 Fax 413-587-1272p� APPLICATION TO CONSTRUCT,ALTER, REP E V E E*1 A NE OR TWO FAMILY DWELLING JUN - 2004 SECTION 1 SITE INFORMATION echo 1u be completed by office 1.1 Pro2erty Address: ra�3 Fes,-r3otcS:ci� �3rGl -- — ap,�� f dot:� tt d I cZ— 3 �Z Zone _Overlay 1D15ti7Ct Elm St District ;cc D�tr ct SECTION 2-PROPERTY-OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: rte— L--9 L:L✓-t wit j2-c�i���� �- --f-J� Name(Print) Current Mailing Address: 5 e2- —cc,919 2 a a—Telephone - Signature—/ �� ,17 (cal l iZiG i�t1�UP_f'►„-�P�/�18�, 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 bv permit applicant 1. Building Z Q,C::)C. (a)Bultding Permit Fee 2. Electrical h d� (b)Estimated-Total,Cost of Construction from 6 3. Plumbing `.�-. 6 I ©C:)C) Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total = (1 + 2+ 3+4+ 5) �-- i"+"' Check Number ( O This Section For?Official Use Only Building Permit Number: ti Date Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2004-1255 APPLICANT/CONTACT PERSON ROBINSON SUSAN M ,�n ADDRESS/PHONE 308 BROOKSIDE CIR FLORENCE (413)582-6992() C.° o U O PROPERTY LOCATION 308 BROOKSIDE CIR MAP 36 PARCEL 143 001 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 Typeof Construction: FINISH BASEMENT&DEMO 8X 8 SHED 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 INF( ATION PRESENTED: I Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Pemut With Site Plar, 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 Comvnittee Permit from Elm Street Co 'ssion 0001 oe �6 20G� 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. 308 BROOKSIDE CIR BP-2004-1255 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 36- 143 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-2004-1255 Project# IS-2004-1895 Est.Cost: $4500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor. Lot Size(s4. ft.): 15115.32 Owner: ROBINSON SUSAN M Zoning Applicant: ROBINSON SUSAN M AT. 308 BROOKSIDE CIR Applicant Address: Phone: Insurance: 308 BROOKSIDE CIR (413) 582-6992 O FLORENCEMA01062 ISSUED ON:6110104 0:00:00 TO PERFORM THE FOLLOWING WORK.-FINISH BASEMENT & DEMO 3X 8 SHED POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspe,Aor 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 6/10/04 0:00:00 2217 350.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo