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28-060 (6)
��tiAHfP�. 0 0 g� Crz of Wort4aiuptan � � jllTassacf�issrtfe -, 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 has/her construction sups:,,isor. 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 - 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 � -- 0 Address of work location C'l�zft�1 Of lartl1gillipfoll 6 [S5Arilli5tt15 DEPARTMENT OF BUILDI) G INSPECTIONS 212 Mairr Street ' Municipal Duilcling Northampton, Mass. 01060 NVORICER'S COMIT'ENSATION INSURANCE AVIFLDA�,gT I, %with a principal place of busiresslresidcnce t: do heret)}' ccrLul un:'cI- tllc' p ills ?.na pCil?ii1CS OI petJillll thRi: ( ) I am an employer providing th'c ollo`,.'inL '.:orr:crs compensation coves e or my employees wor-king on this job: (Lasuanc:: Company) Numb--r) --- (Tr},LiT tl 1 Date) ( ) I ant a sole ?roonetor, ,general conk cr o- Ton emvoer (ci:cic one) ?Dd. 't;a`.-e hired flic contractors listed beio,v ,; :o ,'orrie s c0m0 neon es: (Name of Corllmctor) (LnS IiC C^vIP.^?'i'j:I Gi1Cr Nulrlt--i) � ?'; i0' Date) (Name of Conti ctor) (7a]surinc Coy r,`vPG!iei' Nt r1r) (1= r Iio Date) (I"'ame of Contractor) (lI1S 3I1CC CD ;;3]:i/PG�;c 1 i1II?1,'r) x-,:T o-n DatC) - (Name of Contractor) — jaslmnc:. Coai ny/Polite NumbLr) i (. 1 i1IT1 a sOle hiLVC nO 0I1C 10^,- I am a home C;AI,'I]C' NOTE.:E.:plcsc tx ntruc t}sr,tip i7c l <rc:�.zr-a t ,o r tv, i;c^..: i.v21!ir:,c. not utoce t1Ln thru uni'�i^tc f dt he];r, � .1i.�rr_:��of a; ca'•�loyc3 un c t}r tw;L:- _cc z irn r.(('L1<� - tronncr for e i ccsc or t?-t rtr..:c 'cr,-c 1c9a1 etatuc of cn employee under tun LL'ev?tcrc l 4o1-t- iicm!.eL I unde.^itand that a copy of t}v etat—=:n:ay bo to L»IYt ort v of tnd s riel/n-ids to Ciu w of is r�-a for the oovcrx&C vaiGcatioo grid that f_.iltuc to r-a c coti�r�urd ; c�.iM 2S.A of'.tGL.152 can kad to tlx intpositia�of r i._1 ptt nl::u Oc)aiistmg of a ftrr_of tip to S 1-50000 m:r I x i^:�rixr.:c^1 of tip to Cr'-.)-Zr e:-.I evil-,<mI iea in do firm of a sty'` 'ni:Ch _:-,;1 e Lrir of S 100.00 a day igtin:.l mc. . Fcr dq:uvlrstal"only / —z?%°`' �/-•�_�i S `� •Ufa f.'t:t*;.'.: 1,<): ,. Jt Pia turc tYT,ic,.u;c^JI'cr-11-1 c-: r .. SECTdON CONS�RUGTION:SERVICES 8.1 Licensed Construction Supervisor: Not Applicable W/ Name of License Holder License Number Address Expiration Date Signature Telephone Re s e ffi orn mR=ouernent� .;,�t.a;.t�. 5 Not Applicable Company Name Registration Number Address Expiration Date Telephone SECTON30�WOI_RS' COMPENSATION 1NSIIRANCEriAFFIDAVIT;(M)G.L..c. 152, § 25C(6)) .. �. 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....... ld No...... ❑ •'i1 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 aeecptable 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 Lawns and State of Massachusetts General Laws Annotated. Homeowner Signature i i CT O 5, P4TdOT 1QV,RO PO"BED��iYORK' check;aL1 a I1 abhe � ,�;��r=n. ",, °�&,' .nx= b., ...�t _..,,•::::, smz �: .z.,.r ,r.zt.=. �.��;M ..: � a�,� �.3.a.� New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ . Or Doors *L Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ Other[ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes X No Adding new bedroom Yes _ S No Attached Narrative 0 Renovating unfinished basement Yes —'K_No Plans Attached Roll 0• Sheet 0 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 SEC ©l Y ERAUTF]OtIZATION TO BE COlV1PLE�TED z WHEN OWNEf�SA ONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize to acs 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 ie Signature of wner gent Date y Section 4. ALL INFORMATION MUST BE COWLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by Building Department Vontage 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 DON'T KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T 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: r r ity of Northampton at uilding Department _ 212 Main Street ` Room 100 No thampton, MA 01060 T ' �S � 13. 87-1240 Fax 413-587.1272 a OEM Uf F)U APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1!- SITE INFORMATION - This sec#ior%#oeco aP eteb office %� 1.1 Property Address: Map ` o ct># x EIm,SfDistrict .E� CB U-�striot ' ' SECTION - PROPERTY OWN ERSHIP/AUTHORIZM*dENT 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION'S:- ESTIMATED CONSTRUCTION Item Estimated Cost (Dollars) to be Official Use°Only c m feted by ermit applicant 1. Building J—�© ©� (a) Building Permit'Fee 2. Electrical (b) L:stimated 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 15� This Section For Official Use—Only Building`Permit Number: Date'Issued: I Signature` Building Commissione0inspector of Buildings L L Date --z a ;. BP-2004-0342 G1S#: COMMONWEALTH OF MASSACHUSETTS -` CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2004-0342 Project# JS-2004-0497 Est. Cost: $500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 143312.40 Owner: VANASSE STEPHEN F&JOANNE M Zoning: RR Applicant: VANASSE STEPHEN F &JOANNE M AT: 374 SYLVESTER RD Applicant Address: Phone: Insurance: 374 SYLVESTER RD FLORENCEMA01062 ISSUED ON.9/26/03 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE EXTERIOR DOOR 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 Occupangy Signature: FeeType• Receipt No: Date Paid: Check No: Amount: Building 9/26/03 0:00:00 2373 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo