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25C-247 (4) O O I ity Jaf 'Narthaillptolt z � � anrtassacftusrtPs I� _ 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 iris/her construction super,-` or. 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 de 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 _lo Lo 3k(c Address of work location 17 Q% —T ,2�u ICJ p r 4 t p1 o GG3.c��yE Q- t7f ��L1L"f1�i1111�7f011 _ f �lasanchncclle' is c� DEPARTMEMT OF BUILDr)tG WSPECT101.'S - i - 212 Alain Street Municipal Building HorLhampton, Mass. OlOGO WOMCER'S COiY[PENSATLON MSURA-NCF- Al=1 AVl-j- ,VILL a pi-mcipal place of business/residencc at: — (phone') do hereby certify, under tlic.pains and penalties of perj-ury, -h:l r: - ( ) I un an employer providing the follo,,vine %vorkcr's comocnsaL ion cove:mgc for my i' etnplovecs Nvor-�Dng on Lius job: { (Luu-r-an=Compz-L,,\-) (P0U r) -- (r:•plr.:tion D2i--) I O I am a sole proprietor, general contractor or homeowner Icicle one) and have hired i the conuactgrs listed below wbo have the foflo-wing workers comp°rurtion policies: (came of Cortnc or) Grisuranw Datc) (N:me of Coomaor) ([nsuranec Compare}fPotie \tuncrf) (Li�ir tion Date) 1" (Name o(Cot!>zaaor) (Ltuurancc Comm)/Polk} t+ttsbcr) (ExAirt7oo Datc) (Name of Contractor) (Lasuranc-- Comrazy/PoLicy Number) (Expiraiioa Date) . (aIIa(:]�rC•ocal 'c.k^C,ifnc�i�•to¢tc?u�irS«a�•ioa pc�.iaiag to.il cc�-r�:z) . ( ) I am a sole proprietor and have no one wor�dDg for me. I am.a home owner performing all the work myself. NO lam:plc-=be cwZrC vi is 6cm�vcn ubp aU=PI%pcsoua LO do ocr c=—,,=,1c G rc,aII cl,, l_i:of ant tnoce tb---U =ru in uiieh the b.=.o na-raid,.oc ca the zpputtea.ar7 th—� :-c not C--ne-.Uy xes:d.-rcci w be employes unc e the..`Oz -'�c==p�ha Act(GL152=1(S)�_,,wLcLhon by a homeoavc far:bcm=a permit rs_y--,d—the �'� Icy.!n,,.,oC an cr�loyx uadsr dap Worico�a Coaapamatioo.AcL 1 uadesz aad tcsa>Dopy oC tbi.mtemoat may bo f«-c.urd.ed to tba Deparcmmd of ln�+triel Academy Qffioe of Iru+`•non foe tb, cova�.sc veitfesioa a-'rd Uu L-L-r--t.o ceeurc'eovcry�-under scetioa 25A of MGL 152 c=Icd to tba ixpasaioa of a=dwi peuiLio coma: of a Ene oCtrp to S I-MOO and/or oCup to Doc yc-,end ciNit p=.pja is the focm of n Stop Worti Order aad a CMa of 5100.00 a d_y apuatl me For Permit N=Lxs c71$CCfP.Lin,�%Dr` I,bn� Lot Stpaacun of Li( crrnlucr- Ag or SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone . -- .. 1 PP Not Applicable ❑ S�:Re4ateredFllom'btmo verhent.Coit't' cgo Company Name Registration Number Address Expiration Date Telephone SECTION 10 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GcL.c.152,.§25C(fi)) 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 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 u dersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of No, ampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. omeowner Signature_ 0 / X SECTION 5-DESCRIPTION OF PROPOSED WORK(check alt applicable) I -- New House Addition [- Replacement Windows Alterations) Roofing ❑ Or Doors 17-1 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[0] Other[C7] E�P(e Description of P rp o� d ork: Cc Ph Y ` t S t' r.rt l�i Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa IAN.evlr Et©rrS aetc�©tFa d�tlo o.ex�s i ous�pomp eteFt' 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 y 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. 1. Septic Tank City Sewer Private well City water Supply SECTION 7a-OWNER AUTHORIZATION-TO-BE COMPLETED•YWHEN OWNERS AGENTOR CONTRACTORAPPLIES FOR BUILDING PERMIT I. 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 the pains and penalties of perjury. Print Name Signature Owner/ ent Date Section 4. ZONING All Information 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 Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Perm it/Varionco/Findi ever been issued for/on the site? �� �� NO ^���� DONTKNOVV �_� YES �~� |F YES, date issued: IF YES: Was the permit recorded ut the Registry ofDeeds? ' �� NO �� DON'T KNOW 0 YES IF YES:� enter Book Page; and/or Document#' ' �� �� �� B. Does the site contain a brook, body of water or wetlands? NO v�� DON7 KNOW v�� YES v��/ IF YES, has u permit been ur need to be obtained from the Conservation Commission? Needs tobmobtained �~\ Obtainad �~� Date \~� �~� ' C. Du any signs exist on the proparty �� ��� YES �_/ NO x�� IF YES, describe size, type and location: � - D. 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,gradingexcavation,or filling)over 1 acre oris it part o�o common plan that will disturb over 1acre? YESC��) NO ���) IF YES,then a Northampton Storm Water Management Permit from the DPW is required. IA I City of Northampton Statusfit >, ttD� f�' fl ,-4m.en+ EJ�. a D"n ._�n-m+s.a. ,i,.,�ssr-`, � •iw<. r gJii,. ing veparuu • � V++. tv 212 Main Street evesetA uCy � � h i Room 100 lateixEllArf Northampton, MA 01060seta� � ia phone 413-587-1240 Fax 413-587-1272 PIkSte^PCans a APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTIOR.1 -SITE:INFORMATION 1.1 Property Address: r: This sectiorrto he campfeted by office LOO /� 1 tT� D F-(vq RoCIA • JU G TYI CC tn6c. O C D(�P done OverFa DEStcict EfitnS Distr►ct ., ;• GS DIsfrtct _. .. SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEDr,AGENT' 2.1 Owner of Record: 'i & '00a Name,(Print) Current Mailing Address: �( cs= Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTIOWCOSTS;: Item Estimated Cost(Dollars)to be Official Use Only -. completed by ermit applicant 1. Building , Building.Permit Fee 2. Electrical (by.-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) wvw Check Number This.Section-For Officfair Use Only.., Date - Building Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date 17 OLD FERRY RD BP-2007-0380 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C-247 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-2007-0380 Project# JS-2007-000568 Est. Cost: $0.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 20124.72 Owner: BOBALA JOHN J&KAREN A Zoning: URA Applicant: BOBALA JOHN J & KAREN A AT: 17 OLD FERRY RD Applicant Address: Phone: Insurance: 25 OLD FERRY ROAD 0 586-2704 O NORTHAMPTON MAO 1060 ISSUED ON.101512006 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL SIDING & INSULATION 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 10/5/2006 0:00:00 $25.002866 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo