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25C-011 (2) ri if � � j�Iassacl?usetfs DEPARTMENT OF BUILDING INSPECTIONS / INSPECTOR '212 Main Street • Mmiicipal Building Northampton,MA 01060 5 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 sups. sor. T lie state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two faff1Ty__-_ 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, 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 r ' r Ti i � t7f � art a111:Pf011 - Q f qja3amchnsrlla' c� DEPARTNIE14T OP BUILDr)\'C INSPECTIONS 212 Alain Strcct ' A[unicipal Building Northampton, Mass. 01060 wolUCC Z'S COiNITENSA'nON MSURA-NCE AFFMA. IT I AA (ti ccvsxJperml ttcc) \vith a principal place of businesslresidelnce at: _-- VS. - V*'V\V-'l (ph 0 0 c 7.) sar--t/ci t}Isiatc/a p) 610 T-5 do hereby certif)r, under thc.pain5 and penalties of pcguf-y, hal I am an employer providing the followine''worirer's comocnsZdoP cove2ge for ln), emplovccs wortzng on this job: W\✓o�SS co�( Cog%— Do I u—OA.0 (Insu.r-an= Comp=v) (Potie:Niumbcr) (r:pir�tior Date--) ( ) I am a sole proprictor, general contractor or homeowner (ci:c:e one) and have hired the cone actors listed below wbo have the foUo%vino worker's caMpensadon policies: (i.nmC Oi C0at7nci0r) (Insuralicc. CompaJlyil"OUci NILLM=---') �`•�1iJ 3^?1�1tC} (Nzmc of Contnezor) Gns- mace. Comoaa}r/Po!ic; Nuns^_r) (-Expir.:uon Date) (Name of Coauaao.) (Insu-ane: Compan)-RoUq- Number) (Expiraon Datc) { (Dame of Couaacior) (Lnsuranc-- ComrznyRoUcy Number) (Expirlioa Date). (aII1Gy1 zd1.:or31 bcQ.if ncoarn tp¢iGiti(�-iafOrlaa.-'l on Pclaiu�.as In.Il w�-1.•.v:-�� - O I am a sole proprietor and bave no one wor4dDg for me. ( ) I am.a home owner performing all the work myself. NOTE:pl=c be acrxra u—N e ho. -ocn wto calploy p<=-tom Lo rSo r• r`stloo c rcpau waric on r d—Lb—nz or ant meta tbcn ' eta in w' ch the bomoownc r mdo or oo the awac i+ zppurtenri tbe-e�,ox CC _!Ty oecz:d=-Cd w Lc cixploy—unCc the Nei ct cc=p--.ioa Act(GUI 52=1(5)),:,oplin.ow by a bomeoQaa far a be=--a permit=y--id—the Ic�1 ct�ac oraa—:ployx uader di WarkOea C.ompomLLioa AeL i lI uodaztiad d�a a Dopy ortbia mttm-.l m y be foc--,ded to the D p-,.Od of t,—foc tb. eovea.sc vtaiC esiioo aad lhet L•iltae to socurc rovcn�e trader section 23 A of MdL 157 an ied to the rm�aioa of aim;a�I Peoria ooasisiag of a fwc of up to S I,500.00 andfcr of up to ooc yr r and a%il pcoxkui in dx form or a Swp Work Order aad a Gm 0(:S 100.00 a day Lviast m-- For d,,-=+�u.c ontr - /1��������/ pCTLIIII NtSIDt--r . Lot 3 SignaWn of Uc=L5cclPcrrniucc -ate SECTION 8-CONSTRUCTION SERVICES t 8.1 Licensed Construction Supervisor: Not Applicable Name of License Holder: License Number Address Expiration Date Signature Telephone �. � � 3:Re rsfere Core:Tm rovemetiCoptraor. Not Applicable ❑ Company Name R gistration'um er - - — Address \ Expiration Date t2--O lN', var 0 kbl'3 Telephone If 3-Sa SECTION 10-WORKERS'COMPENSATION INSURANCE'AFFIDAVIT-(M.G:L.`c.-152,§25C(S)) 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...... ❑ K 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 dweIIing,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 Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature e SECTION 5-DESCRIPTION'OF PROPOSED WORK(check alhapplicable) New House [] Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ] Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[C7] Brief Descripf of Pro o Work: Alteration of existing bedroo Yes No Adding new bedroom Yes O<S No . Attached Narrative Renovating unfinished basement Yes ,No Plans Attached Roll -Sheet sa.�CfrC�eti��to�s�=�andF'� ctrn�u. �x t ac>���rsinct.�eot�p e�e�� ottvartr>�iQ: 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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN` OWNERS-AGENT OR-CONTRACTOR:APPLIES:FORiBUILI*tG,PERMIT as Owner of the subject property hereby authorize Y v�'r( � J V12-X21`4 \ to act on my behalf,in all matters relative to work authorized by this building permit application. Signs re of Owner Date I, w1 w 2 5 va✓l.to!'=t n 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. ' VV\,,4,rt Print Name � �—� Signature of Owner/Agent Date Section 4. ZONING All Informatibh Must Be Completed.Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filmiaby a Building Department"> x.: Lot Size I Frontage ` Setbacks Front Side L: R:` L R:' Rear � [ i Building Height - ' Bldg.Square Footage ; i % i Open Space Footage r__ % --� �--- (Lot area minus bldg&paved L_ � I parking) #of Parking Spaces Fill: (volume I&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DON'T KNOW YES 0 IF YES, date issued:': IF YES: Was the permit recorded at the Registry of Deeds? NO Q DONT KNOW YES I IF YES: enter Book : Page. a and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained Date Issued: C. Do any signs exist on the property? YES 0 NO 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 IF YES, describe size, type and location: f E. Will the construction activity disturb(clearing,grading,a cavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 , NO i IF YES,then a Northampton Storm Water Management Permit from the DPW is required. i f rt ampton dD �Old partment � 20J (Street Se w il00 e , Northam ton; A 01060 a sb rates n 7 i9 240 fax 413-587-1272 to t an� ��' , ` ` APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTtON.1.-SITE INFORMATION This seetton to be cam�l~eted'byoffCce ,' 1.1 Property Address: " _ (,41 Ab Lot Unit m Ove�fay Drstrccf P� tie": y Efm 6L 0istrrcE SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED.AGENT. 2.1 Owner of Record: _ Name(Print) Current Mailing A�drgss: �� Telephone Signature 2.2 Authorized Agent: Name(Print Current Mailing Address: ©`O 6" 6,1—� 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 Construction from 6 3. Plumbing Building Permit Fee, 4. Mechanical(HVAC) 5.Fire Protection 6. Total=(1 +2+3+4+5) Check Number This'Section de Ofi cial'.Use Only :Date- Building Permit Number.' ` issue(1: Signature: Building Commissioner/Inspector of Buildings Date 164 NORTH ST BP-2006-0006 G1S#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 25C-011 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2006-0006 Project# JS-2006-0009 Est. Cost: $1500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Mark Sarafin 104765 Lot Size(sa.ft.): 13895.64 Owner: FENTON JOHN ROBERT&JOAN A Zoning: URB AppUcant: Mark Sarafln AT. 164 NORTH ST Applicant Address: Phone: Insurance: 81 Russellville Road (413) 527-7812 Workers Compensation SOUTHAMPTON MAO 1073 ISSUED ON.715105 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 4 SQ ON DORMER 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 Sienature• FeeType• Date Paid: Amount: Building 7/5/05 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo