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25A-132 �'CtU►MP�. Crzi� r of Xarthaiiiptan L r • r flldassaChltsltt5 ' is DEPARTMENT OF BUILDW G INSPECTIONS INSPECTOR 212 Main Street • Municipal Building 7 ,V 5`e y: 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 iris/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 S I, lei C, ti al,� �;� 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 S I/W Address of work 4 location �s � � e- { U'itIT of artilaillpf Lill � 6 firaseRChnertfe ' ^z m DEPAR"T1.1-NT 01' LUILDrl�G INSPECTIONS 212 Maul Street ' Municipal Builcling Northarnptoii, Mass. 01060 WORKER'S COMTENI SATION INSURANCE A-TITI AVIT Wtl1 a principal place oT business/ c:idcnc _. �a ire ry . .«�: 4- 0/o lti o (�l h c:n c.'=)JAI -`��y ob , ----- -- -- >_ ---------.- - 0 — - - —— do hem by cCndy, L':I er Tc pals ;-,nd pcna hies of pc'.rjllf�" l.fli!i I am all employer providing the i011O'wDnC ••':oDkes colnpcnsati0I1 cove:-2L`•C ciuployees wort lrif, on this job: anssrant~ Co>Ip?m') elic.NL>_ LErr) ---- ���r���Date) �l-�-s9�•t`�. �-i':st���`�c?_i~�-•--"alt:`.- 0+� '::-.1?y'�{tp(}�P�$'C!3f"i!t)®f1L�,�fjFi-; �:ii�*.'°S: (T:nmc of Cons icwr) C nsu ncc Corm r click P�'ulntYr) (Lx,.,::r..ic;.Datc) (Name of Contr:cto-) (I as-u-_nce Coin, D,_,iy/Pc.!ici Nurlli'r; (3 zpi tin l Date) (Name Of Coaaanor) FE tii;:,-."^G DaI'c) - (Name of Contractor) - (Ins,.ranc� Comr'=v�Policy NLImr--r) - (Eg,.-:tior; Date) (^.(LiGl:.Ct"±S']OC:�.I S:'._Gl''•`r.^r f. '.7 ^r:..''Y.':�::_"Y:".t':�t`.P A C.-C:_:_Ma:) ( 1 a-'n 2L olic wot"hy fOi ih,... NO'IT:please be aworc L:z:. iic lxtrr_o.:r-s.i.o r. pf._v I>a n:q:rte '_:ync4 ar::_nC•, r :=,:aU ..__.._c.cLi not¢tc<c thsn(hrco unH5 in wE--cit rca:.:::I of oc;:w�:•.:..3 z .•r cr rS LF c o c c tr t�_rsa12Y cir:l;,r::=:o ti e:�ployc3 u_ti�r thr_�w;i::,'s ar:x•.—:a'icn i,r.'(GL!52��!(511.- .-:.:ie:, �y n h,rixu-:rcr`cr e Lecx ct p-ra:::n ..'tir.-e t. kPI now;of an Mphyx und4T t1.`o Wcvicor"co,•z-nor tian?'cc I undc--:ttnd SO i cmy of O2 ctatct:s'r_-y bo foe-,vdn:i to t_'»DYI u t.,­:of Ir>iLM1:.i-J M-'iL�rJr�'Oilicv of i:::+-,rR.-rx for ttx eovcm&c vaifi=1ion and that f_iltuc u,3.: 25A of MK31,152 can De_d to tl>e iftpo;iiim comistvcg of a fur-of up to S 1,500-00 etr&'o of::p to rn-y e:-.J civil j-n.ILics in I,,lean c•f n S!r.,,`;J i'.54 s:1 Lrm oCSIOp.00 a day rr�-in:t m.. . foe dq=,.rums�r use catty . -6 � Ycrrnit N __I LLL T 1 Signature of T , L SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Re > ere- -ome m-r uernen. Con rac Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT(MG: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 acccptable 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 15') (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 an State of Massachusetts General Laws Annotated. Homeowner Signature I I a 1 1 SECTI.ON'i DES DR.RgT4 NtOFzPROPOSEQ' 0RK check 11',-rtbdlk able New House ❑ Addition J Replacement Windows oofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other[ ) Brief Description of Proposed Work: I h.S-1-cc 2, w I i7c _Us Alteration of existing bedroom ✓Yes_'No Adding new bedroom Yes No Attached Narrative D Renovating unfinished basement Yes No Plans Attached Roll D• Sheet❑ 6a. °.�." =flu n <r�a�dif-ion to existin;?�°h.olisi�riTgornp le""�"e-�#herollowiri, 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 SECTION a��OYYI�ERAU'�H'D'RIZATION TO BE COMPLETED :WHEN 01lYNfISJaENT��O{C�NTRACTOR,APPLIES FOR BUIL[21NG PERMIT I, 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. Print Name Signature of Owner/Agent 6ate 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 DON'T 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: tt� f of,,Northampton � E C t� Q l u ng Departments 1 Main Street 1 MAY 14 200 j j om 100 ort ton, MA 01060 -phone 413-�871240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 SITE INFORMATION r , Th-s secl�on to be Completed fiy ofl';ce 1.1 Property Address: s 5 u A a � ct t� Map -((��cLU tlnrt x r �; a✓th x u °w' 9 7 u c., �w "'v ,a� n.. iD1/erlav DlStf7Lt 4 1 V fir' r IQ OA � YI I�CL F r 3 k 3 ,_ c ®t17 .©ISCrICt s DIslayct SECTION 2-'PROPERTY`OWNERSHIPJAUTHORIZED.AGENT 2.1 Owner of Record: f� /` i 0661 d' F- " Ann& 0 S'►'b �� 3`� 17a�I 19ye Name(Print) Current Mailing Address: x, 4�-t XXV— X�IA2 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 ws '(a) Building Permit Fee aca,K�acrJS �7S_ 2. Electrical (b) Estimated-Total Cost of Construction from fi 3. Plumbing Building!Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 +4+ 5) '� �s� �� c Check Number This Section For Official Use Onl Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date .a • 39 DAY AVE BP-2004-1140 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25A- 132 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-2004-1140 Project# JS-2004-1709 Est. Cost: $375.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sa. ft.): 23565.96 Owner: SMITH RICHARD F&ANNE D Zoning:URB Applicant. SMITH RICHARD F & ANNE D AT. 39 DAY AVE Applicant Address: Phone: Insurance: 39 DAY AVE (413) 584-8227 () NORTHAMPTON MAO 1060 ISSUED ON.5117104 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL 2 WINDOWS IN BEDROOM 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 1535 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo