Loading...
17C-005 (3) r • u $ � �iRassachasrtts n DEPARTMENT OF BUILDD\'G INSPECTIONS /= INSPECTOR "212 Main Street • Municipal Building Northwnpton, 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<:•-,•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 fame ' 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 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 Pf �\T0 fljzIIIIptoii Ay f 3aAc4nsrlla' _ o DEPARTMENT OP BUILDf?\,G INSPECT(O1.'s - 212 Main Street kfunicipal Building Northampton, Mass. 01060 W0IU<LR'S CONDENSATION MSURANC- A TTI AVIT' I, __ffol t ►d ra ru0 / _Ga(2 v (liccusxlpermitfcc) - - -- %ith a principal placc of businessfresidencc at: -- — -- < >�-?oMCF— V-1'2 riA � /� ��/a f (phone:') (s�t/ci i`r/statcf�p) do hereby certify, under the.pain5 and penalties of perjury, :hat ( ) I am an employer providing die followine!,vorkcr's comocnsadon cove mac for Iny emplovecs Nvorong on dlis job: 0MSUj--n=Corer,•) (PeLie: Nu rr) -- :pir�aon Dzl^) I am a sole proprietor, general contractor or homeowner(c cie one) and have hired the coca-wars listed below wbo have the foUo%VMQ worker's G00;)ensation policies: �n�rF2rc�i✓ (J2�-ryro�,s- �� Co�,n����n�Sr /3,�/D9'aoa/- � _%`�� (-Name Of Co:mlao') Grisurzncc ColnpanyilioUci Ntum-C) 0:711-aeon Date) - (Name of Conazclor) (lnssraacr. Comoam-iPolim, Numcrr) (-Expirt:aon Date) (Name of Co=C-10;) CLasurance Compan}'/PoUq- N:,sb,r) (Exairdoo Date) (Name of Contractor) CLasurancz- ComrzaylPoticy Numb r) (Expiration Datr). (aII3G]_ddi::or31>icC,ifn--,to incucL infortna;on pertaaaias w.11 { ) I am 'a role proprietor and have no one working for me. ( ) I am,a home oNvuer performing all the work myself, NOTE:pl=c be Lw7ur tba:Mt-je bcmrAV Vm tY(,.Cmplay pczoni to dJ o-- -sago c rcpair wori;oa a d%,r1-g of ant mero th n 4�iw_titr is 11-b +61bc bom.—.cr reach oc ea the pvunC,rpputica r�tbeeo L,otx C._H-Dy ocx--rd=-cd to be cixploycs 11 v +the..v i c{:c=p=.-aim Aa(GUI 52-=1(5)},npptia.ion by L bomco--=fm a lien;=or pa=A tr_y--id—tbC Ie-P.l eta u of La cgloyer under dW Wori ,Compomntion Ad I--Z-Mazd th,a a Dopy of thu mtcmem may be roeanu-d+d to tba Dequtmo.d of Io�iXriJ Aecdm(n'Offiw of Lrur+oen far the oovcraS-c veilatioa and the L•iltat to"=I-)cov rmt tine',-ioc oa 25A or),(GL 151 an(ed to the i=Po:aioa of mimiasl pca&Wca oomLSUtg of a lint or up to S1 yQ0.00 and/or 6naiyo�orup to Doc yc,Lad avil pm hia is t5c form of.Stop Work Ordc and a Gm of S 100.00 a day apinu m-- / For use only tun hl-,9_-� �crmlt Ntxr Lot• �' Signature of L: R SECTION 8-CONSTRUCTION SERVICES t 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9.Reitestere Efomh fima�avee ent f a ra a � :' Not Appliiccablle/❑ y Comp anvName Registration—Num er -- �--- Address Expiration Date Telephoned SECTION 10 WORKERS'COMPENSATION INSURANCE AFEiDAVIT'IiKG: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...... ❑ 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 Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature r ,i SECTION 5-DESCRIPTION'OP PROPOSED WORK(check-allayolicable) New House Addition Replacement Windows Alteration(s) Roofing Or Doors C3 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[m] Other[p] Brief Description of Proposed Work: _K _/1_11 cz__ C6 JV Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet . 2+ 's.aa.�:} 't w'^;�.2:'..�: "...'.. .-� c°. „� r;;;•m. 'z .�,5°:" sa rf IVevi�FzOUSe and r do i#�an to eacistl�cl CZOastltctRcampCe fhe 0[(aurcir'�g 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 L 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'WHEN OWNERS AGENT OR`CONTRACTOR APPLIES FaR'-BUILQING PERMIT- l 14rll'Ll &T� d ZA as Owner of the subject property �- hereby authorizes 7�ni/92P7 ( lLt� � to act on my beh f, in all m-atters r ative to w k a orized by this bui ing permit application. L Signature of 6wner 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 of Owner/Agent Date ' F � 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 j Frontage Setbacks Front Side L R: L: R: Rear i..--�. Building Height J 3 f Bldg.Square Footage (-- €— % Open Space Footage _._; % (Lot area minus bldg&paved 6 = arkin #of Parking Spaces Fill: (volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 0 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 0 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 Q IF YES, describe size, type and location: 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: 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 . NO Q IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City of Nortoa mpton Iding Departmentma 212 Main Street e s t Room 100terle i w �nnA mpton; MA 01060 Nov 5 pry 4 - 1-1240 Fax 413-587-12725 � fIWSTRU ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION`1,-SITE INFORMATION 1.1 Property Address: This section to be completed by office A/l Map` Lot Untt Xr F/_0 Zone 16y''Disfrrct /zn/Goc /6q f'9 f i Elm=Sf Distoct •CB D�str�ct SECTION 2-PROPERTY OWNERSHIPlAUTHORIZED AGENT, 2.1 Owner of Record: I Name(Print) Cu aiiling Address: _ Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3.-ESTIMATED CONSTRUCTION COSTS fCp ©C'rJ GL 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: 1 Building Commissioner/inspector of Buildings Date r 30 LAKE ST BP-2005-0556 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C-005 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-2005-0556 Project# IS-2005-0736 Est.Cost: $6000.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Edward T Corbett 119488 Lot Size(sq.ft.): 12327.48 Owner: ESPINOLA LIEBERT DIANE Zoning.URB Applicant: Edward T Corbett AT. 30 LAKE ST Applicant Address: Phone: Insurance: 1 TERRACE VIEW (413) 584-2546 EASTHAMPTONMA01027 ISSUED ON:11 18104 0:00:00 TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF 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: Receipt No: Date Paid: Check No: Amount: Building 11/8/04 0:00:00 MO $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo