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25C-048 (6) t 4•SHAMP�. of Warthampton $ � �ilnssachuseifs - 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 780CMR 108.3.4 to act as Isis/her construction supc. .;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 fami -_ 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 r',egulations. 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 rouzh 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 ade understand the above. (H a owner/resident signature requesting exemption) I will Ito schedule all required building inspections necessary for the building permit issued to me. Date f Address of work location �•C ttno-r aT � �y+ Crib of ( ;a� fl1a�ItPtoll ?aaa itch nsrlla' o DEPARTMEIJT op BuiLDI>\jc INSPPCrtot,,s 212 Main Strcet Municipal Building Northampton, Mass. OIOGO «'OR14:IZ'S COMT'I✓NS -aOIN MSUR�CE A17FUj,,i.«-z'. (hcCaSxJpermlttcc) -- - -- %VIth a principal place of businessfresidenc- at: - — - _. (phoney') t/d t`J/aatc/�P) i do hereby certify, under the.pains and penalties of penury, .h:i ( ) I am an employer providing die followine'%vorkcr's cotnocnsaho; cove age for Inv employees ivorldng on this job: ! Omsu --n=Comr,-my) (P 0 U Cy N,unabcr) -- :-piratior,Das<.) i i Kthe am a sole proprietor, general contractor or homeoi�,ner (6 cie one) and Lave hired nouaetors listed below wbo live the `ollov Q workers raooen_-2i3on peLcies: (1+II17]: of CO ! .. i0") (In-surzncz Coinpanyilt GUCi }�ruIIl <r) (Zw:Jl+d�^R D.-itc) -- (Name of Coocactor) (Ins lrznc Compaa`rPolie� \t n�crr) �i�irtion Dale) I i (Name of Connaao,-) (Laauaucz Comnan}•/PoL-c)• N;imb:.r) (Exairz6on Datc) I ` (Name of Coalydctor) (Losuranc—c Comra.n-y/PoUcy Numbs) (-.,,pL loon Date). (aasr3 �'oczl�cC,f accaa�-to acv aforatii oa pertn,'g to.U ccC:-to:�) I am=a sole proprietor and bave no ooe worming for me. I am..a home owner performing all t.be, work myself. NOTE:plesc be ca-uc tt,.wf ]e bcmrvcr� .bo aaploy pezonz to - -r�oo c rca nor c oa.d..ctl��of not morn th_a t`su L-nis in tvSc:h the bomo� rtmd,a(x oa tb.c p-ouc,:b zpput�tbero ooc C...):Z-f occ d—d to be citploy=unG the..fit An(GUI 52-=1(5)),=gpUciEoo by a bomco -oc fc=n lac=_or permii n_y CN-id�LL-c l cgs3 ctaBU of ea eraloyx under daa W ocSc.o(a C.ompemal,ioo Ad I d th.d,a Dopy of thi.mt®m2 m,.,y be for-+.vrdn.d to cbe pcpartmml of In�+Xiic!ncvdc¢ts'Offioe of 4aur+ooe for th. COY rciGessioo and th t Liltae to se azrc koveraZ,=ux 'section 23 A of l tOL 152 eza led to the iaapatiiioa of crimirW pcutWcs oomr.:n•.x�of a fine of up to S 1}00.00 andlor�M� of up to Doc ycr Lod civil prn.Pua in 6c form of a Stop Work Ordcr end a - fim of S loo-OO a d_y a�inA - / Pcrmit Number _ Lot : Si of Lia�scc/PcrmiU- SECTION 8-CONSTRUCTION SERVICES r 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone S--?e sler"e�ii-.Ro- l i`riirrein�en opt a��fa Not Applicable ❑ Company Name Registration Num er -- Address Expiration Date Telephone SECTION 10 WORKERS'COMPENSATION INSURANCE AFFIDAVIT` A,.L;c.152,,&25C(61), 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...... ❑ rt ; rem 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 Ordinances,S to and Local ning Laws and State of Massachusetts General Laws Annotated. Jorlhampton omeowner Signature r v SECTION 5-,DESCRIPTION OF=PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacemer Windows Alteration(s) Q Roofing E] Or Doors /®" Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[O] Brief Desp�ipti of P pose �Oil �rkrt _ork: V, CP r Alteration of existing bedroom Yes No Adding new bedroom Yes No " Attached Narrative Renovating unfinished basement Yes _No Plans Attached Roll -Sheet :+rca rg*} M1°-�ex ._' :>^ "!..-� .�:;? ,_ ATM.✓."'"".`z" .`," -'" .,: :�-ate; r s ., i > "amsimd ears'��ecrz�I.arlslna.,_cor�l��et�=�h��E{Qwlg: 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"AUTHOR IZATION:-TO BE',COMPLETE© WHEN OWNERS AGENT"OR CONTRACTOR APPLIES FOR BUILDING.,PERMIT" 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. q'Pn lure of Owner/Agent V Date ' ~ ` _ Section 4. ZONING Al I Informati6h Must Be Completed. Permit Can Be Denied Due To Incomplete Information 4 Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front F Rear Building Height Bldg. Square Footage Open Space Footage F % (Lot area minus bldg&payed #of Parking Spaces A. Has ' m| Perm it/Vuhunca/Findi ever been �suedfor/on the sbe? ' NO DON'T KNOW 0� YES 0 � IF YES, date issued:' IF YES: Was the permit recorded at the Registry ofDeeds? �� NO �� uom'| KNOW 0 'ES IF YES: enter 8onh Page and/or Document# } ' �� B. Does the site contain a brook, body of water orm/ot|unds? NO v�� VV �~�� DONT KNOW YES v�� IF YES' has m permit been or need to be obtained from the Conservation Commission? ' Needs tobeobtoioed �~� 0btm�nm� �^� Oate |ssumd�' v�� _� ' C. Do any signs exist on the property �� YES �~� NO v�� IF YES, describe size, type and location: O. Are-there 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(clearing,grading, .or filling)over 1 acre or is it part of common plan that will disturb over 1acre? YES NO K J IF YES,then a Northampton Storm Water Management Permit from the DPW is required. i ,City of Nortf�ampton Building Department ewa 21,2 Main Street r ti r ",'.)Room 100 Nogham` ton; MA 01060 phone 413-587-1 0 Fax 413-587-1272 e a a APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 =SITE INFORMATION 0011/1 Property Address: This-section to be completed byoffice /(� r / Q Zane Overlays Distnek tact CB District Elm St.Dis SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED.AGENT 2.1 Owner of Record: Name rint) Current Mailing Address: Telephone Sign to e 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 '7 (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 For Official Use Only .Date Building;Permit Number. Issued: Signature: r Building Commissioner/inspector of Buildings Date x 224 NORTH ST BP-2006-0007 GlS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C-048 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category_ BUILDING PERMIT Permit# BP-2006-0007 Project# JS-2006-0011 Est. Cost: $1500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.ft.): 7579.44 Owner: BRODWYN JANE MEYERSON Zoning.URB Applicant: BRODWYN JANE MEYERSON AT. 224 NORTH ST Applicant Address: Phone: Insurance: 224 NORTH ST () 586-8622-0 NORTHAMPTON MAO 1060 ISSUED ON.715105 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS ON PORCH 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: 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