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25C-131 (8) 'S1iAMP ,.Crier of 'Nazthallipto n Z - �� Cilassac}tusrtts DEPARTMENT OF BUILDIN G 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 his/her construction sup,,, ziosor. 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 Ogulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before backfll), 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 thg project until such time as the proper permits and inspections are m de,,- \ 1, understand the above. 1ome owner/resident's sign ure requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Daze Address of work location �o cGa�•°s�� Crii� oflcrrf(Iza))tptail _ _ = P E J+1 a3ahchnrirIIa' DEPARTMENT OP DUILDD\10 INSPECTION'S 212 Alain Strcet Municipal Building Northampton, Mass. 01060 WOMQ:R'S C0,1I'ENSA770N MSURANCE AFFD)r',v1T` (Ii ccnsxJperrni ttcc) V,,ith a principal place of bus;nesslresidencc at: — (I hone-=) (su-c-/city/staic/:r p) do hereby certify, under tbc.pa-ins a-ad penalties of perJuiy, hiI ( ) I am an employer providing the foliowinc- %vor-kcr's comocnsaoo, cove Mee for im emplovecs worming on this job: i (L2s1Lr----n=Comr�-ml) (Policy Ntl_mbcr) -- (r':-pirrtior.Dz1_.) ( ) I am a sole proprietor, general contractor or homeow-Der (c cie one) and have hired the cone actors listed below who hive the followi-oQ worker's coC.2oen_sa6on pakies: (Name of Conmicior) (IL1Rranc-- CoIno3n)Y1iaUci NIuLR-Gr) (—ExJIFdUOn Datc) (N:.me of Conmaar) (LZSUrzncc Comoaa`vPo!ic; `unccr) (–Di pirtion Date) (Name of Conjzaao;) (Lasuranc;Company,(Polk}• Namb j) (Expui z6oa Datc) (NZMC of Counctor) Unsuraac-- Comcaay/Poticy Number) (Expiration Datc)_ (an]�l.:.d;i�oczt�cG,if ncc�..�•to c�cvtL usformi�oa pctn-iniag to.11 cc�-_r�:�) { ) I am'a sore proprietor and have no Coe worhdog for me. I am.a home owner performing all the work myself. NOTE:plcsc be cwarc tt-xi.Az:jc bcm=c.-ocm w-bo aaploy perLo=to o^ c�r�ao c rgaa +orc oo.d..<n: `of ant mCCC tea ltsec tmitr in tr;a�y the bomoown,ruida o<oa the gvua6 zaputten_ra the-en e.•c oa C�,r�!!y oeesid.-ni to be - eixployc� =pplua.600 by a bom�a�fc a hem_«permit rt�y evid�ce tre ]cS-'cttiaac of ea cr�layar uader ihn Woclrla Cocapomaiion Ad I uadc:taad that a Dopy of thi,mtcmcm m.y ba roc�.rnrded lv tb,pcp,rrmcot of In�axricl A—d.•!OIL—or 1n—Cor th. covcrxSc vcriLclioa and tjtu L-i tzc to sccvrc'covcna trod,wccioa 23 A of MOL 132 cna Icd to the iaspositioa orcimia"pcasltio court`m8 of t fine or up to S1}00.00 arw" of up b ooc yt_r e.od aNij peaahia in d5 rocs.or Stop Work Ord,and firms 0(5100.00 a d_y apia:a me for d.;, .-'•t use only - Pcrtml AltML- __ Lot " iv(ap- t. 1 Sr cure o�fu,c � �� _ SECTION 8-CONSTRUCTION"SERVICES a 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone :S.Re` stered tforr[e Iir Faveiriecit Gontracter°}, s K f • "H. ,� Not Applicable ❑ Company Name Registratiori-Num er - - Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION'INSURANCE AFFIDAVtT'(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...... ❑ VIV 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"c ifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances,St and ocal Zo 'ng L s State of M sachusetts General Laws Annotated. omeowner Signature i l r i a SECTION 5-DESCRIPTION OF PROPOSED WORK(check all rapplicable) New House Addition Replacement Windows Alteration(s) ❑ Roofing Or Doors CJ Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [' Other[pj Brief Description of Pro osed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No . Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 66-lf=Nevi=`I ocrse and-©r ddffit a e`xistiii thouslria.co pCete thel fat�aw r : 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 7a-i OWNER AUTHORIZATION,-TO BE COMPLETED WHEN OWNERS AGENT OR-CONTRACTOR APPLIES FOR,BUILDING PERMIT 1, 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 I, 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 t l s and penalti s of perjury. Pr''t ame Sig atur of Owner/Agent Date Section 4. ZONING All Informatibii Must Be Completed. Permit Can Be Denied Due To Incomplete 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:l Rear Building Height Bldg. Square Footage % a Open Space Footage % (Lot area minus bldg&paved I i� parking) #of Parking Spaces Fill: --- (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? N0 0 DONT KNOW 0 YES Q IF YES, date issued:;. IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page, and/or Document# B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW Q YES 0 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 0 NO 0 IF YES, describe size, type and location: r D. Are there any proposed changes to or additions of signs intended for the property? YES NO Q IF YES, describe size, type and location: i _ E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 r NO Q i IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton s Pe Building Department Gp plty tnraPercn 212 Main Street Sewe a t< gat 1 � l y, Room 100 Northampton;AMA 01060t�roSetsfStrc�taf3Parrs � � � � � phone 413-587-1240 Fax 413-587-1272 PtottSitelans Q$hetSpeCfiy r G It APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1-SITE INFORMATION 1.1 Property Address: This:section to e b completed by office / 30 t C� NIaP Lot Unit (` © i.x K Zone Overlay D-, isfricf EltttSf Dfstnct �CBDistnct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Nam ;ate Current Mailing Address: Telephone Si nature 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 (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: Building Commissioner/Inspector of Buildings Date 36 ELIZABETH ST BP-2005-0661 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C- 131 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: BuWbg DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A) Category: BUILDING PERMIT Permit# BP-2005-0661 Project# JS-2005-0882 Est.Cost: $1000.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.1): 3397.68 Owner: HAVER BRAM S Zoning.URB Applicant: MMIC PROPERTIES AT: 36 ELIZABETH ST Applicant Address: Phone: Insurance: 4 ELM ST SOUTH DEERFIELDMA01373 ISSUED ON:1219104 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING 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 12/9/04 0:00:00 1137 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo