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17C-086 (5) ¢SttnM pj, 0 0 g� ti� C�iz#fir of Nart4amptan I � �rtasaath�csetfs "_ DEPARTMENT OF BUILDING INSPECTIONS (NSPECTOR 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 i.is/her construction sup,.: ,- sor. The state defines "Homeowner" as, "P erson(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 backfiIl), 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 req ' ed can D LAY t ,project until such time as the proper permits and inspections are In e I, understand the above. ( o owner/rest ent's sign ure requesting exemption) I will cal to schedule all required building inspections necessary for the building permit issued tb me. Date t Address of work location ,ec cC MA r F `e (rrfL) of �nrfl�a))t}�fflli _ — 9 .. E ��c�aRrhatrtta' _ = DEPARTMEIJT OP DUIL-Df',10 INSPECTIONS 212 ?`'lain Strect Nfunicipal Building Northampton, Mass. 010G0 i �VOMCER'S CONTENSA'nON C-iSURA-NCE :Af'IIJ)����I-I' (11 CL"n.S�'JpCTn1l tiCC) \Vitt a pnrlcipal place of business/residencc at: (pelone'} do hereby certify, under the pains and penalties of per3ury; :hat 7 ( ) I am an employer providing tic followint worker's colnpcns:aion coverage for it)), etuptovees worUng on this job: (Islsur Conn M.) (Pelic:Nu.�r) -- (1 ;pircioR Day} O I am a sole proprietor, general coau-acior or homeowner (ci:cie one) and have hired the conira(+<ors ldste,+ below wbo have the following worker's compep—snion policies: ONSM: Oi Con- Inci0') ORR 1-3.Rte^_ Company/1Po6c) ?�1UQ1LC:) (-ExpirJu0n, Ditc) i (Name of Contncior) (Insuranc Camoany/Polio \tunccr) (—Duration Dale) (Name o(Conl7-a(no;) (t.n.nu-anec Compao)•/PoUq- Numbu) (Ezpirdoo Date) (Name of Contractor) (insl3ran Comrany/Potiey Numbrs} (Expit-.6on Date}- (e xadt ad"_rocal dx-cr if nccos.c:y to main iaforaa =i 00 peta-ininf'to.11 oo�-ten 5) ( ) I am a sole proprietor and have no one worldDg for me. (�[ I am,a home owner performing all the work myself. NOTE:pl sc be ecruc th+.�L le hecan%acrs +bo ctuptey pc;oam w ^• - r=,;:e-oa=rtpau-orz L or CDC most than t t-=rj raid=or oc the Crtuod,zppvrtca rl tb_e,er ox L-m=fly cc-:d rod to be e tployes uar'.e the.. 5 0=�x,.-';ca Act(GL15Za 1(5)�=ppiinrion by.hommava fcr:4ic---.a perma ray c ider«trc i Ic-ga1 CL-=of ea cc7loyx o=dor t!w Woricda Caa3pomatioa Atx I.:adcn.od that a copy or th;.car®ra m.y ba ror-_dad to tb°Dgx,zmmt of JvduxriaJ nccadmc�OIL,-or Ir:ur.000 ro<th. oavQ�vciCatioa�-td ttu L-.iltn to soarrc Lro�crase tmdrr toetion 23A of ttoL l32 as Ica to the i�posilioa oleiminsl pea�lti= 000-tiFiag ora rrae oCtP to s 1300.00 ardor oCup to one yc3r end civil pmxrjo in be Conn of a Ssop Wort Ord-nad. Ciro oC S 100.Q0 a d_y Lparzi MC_ For 6ep.rua�u,e only Permit Numb= _ Z I ©4 Lot^ ` t stun of Licc scdpCfirllLtGC e � � SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone ^s^.f l - Y,:.h^,.,e,.m ,t - , -x�rv'^1,�.-, .. T"S"' '.:.u„ 9�2e4istereci f7ome t%i�prorrerrnent. antractore. r =� ,vVI, _ ,. •K a Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL.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-vear 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 De )of the Massachusetts General Laws Annotated,you may be liable for person(s) you hire to perform work for ou under t pe The undersigned"homeo certifies as s rl� p nsibili or compliance with the State Building Code,City of Northampton Ordinances, tat and Lo I o g awsn Stat o Massachusetts General Laws Annotated. 4 Homeowner Signature ^f SECTION 5-:DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑] Addition ❑ Replacement Windows Alteration(s) Roofing ❑ Or Doors E3 �"� Accessory Bldg. ❑ Demolition New Signs [ED] Decks [C] Siding[0] Other[CD] Brief Description of Proposed Work: 3 (bo%'ylS��/ ° I"�U1 eC' ;C �( �O DirWi"JI Alteration of existing bedroom Yes_ No Adding new bedroom Yes _ X No Attached Narrative Renovating unfinished basement Yes __)L_No Plans Attached Roll -Sheet � " ". � 1,. ."6" el loll t eX1S ll1a��10C15t[� C�filrt t�Q�OtiKillq: s�lf'N�eQase?ate}_ 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. I. Septic Tank City Sewer _ Private well City water Supply SECTION 7a OWNER,AUTHORIZATION-;TO BE''COMPLETED,WHEN OWNERS-AGENT�OR CON`t&-t-OkAOPLIES'FOWBUILpING 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 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. nt Na e 21 Sjgliatur4l 5w- W-Agent 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 — 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 0 DON'T KNOW kj YES 0 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES IF YES: enter Book Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 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 0 NO 0 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: 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 NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. � seOn Marc r � Of Northampton rr,•1iY, fding department 2,12 Main Street i Room 100 r'vG5 Nof h9m,pton, MA 01060 g phone 413-587-1240 Fax 413-587-1272K ; . S rte = AOPLICATION TO_CONTRIJCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION Tf IS section fo be completed bymffice 1.1 Property Address: ` - f (-/7-7- /-F�_ %/ Jn Cl ( b � =Hre�Sr�Distrrcl» �' ' Ci�District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED'AGENT 2.1 Owner of Record: 11-op AT 4- 9e6EecA C_)L4u0EK_ 16 Gc*._5m�)v z- f-t�l,f�lam//`t(. 01V6Z- N e(Print) Current Mailing Address: �� Z 3 7,b Telephone Sin ure 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 ��}/� .G't= (a)Bvilding,Permit Fee 2. Electrical ,(b)Estimated Total Cost of COO Construction from..(6) 3. Plumbing — Building Permit Fee; 4. Mechanical(HVAC) 5.Fire Protection 6. Total=0 +2+3+4+5) (� " Check Number This Section For Official Use Only Dafe Building Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date w File#BP-2006-1386 APPLICANT/CONTACT PERSON OLANDER REBECCA F&JONATHAN ADDRESS/PHONE 96 CHESTNUT ST FLORENCE (413)586-2376 Q PROPERTY LOCATION 96 CHESTNUT ST MAP 17C PARCEL 086 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiniz Permit Filled out Fee Paid Typeof Construction: SHEETROCK& SULATE 3 ROOMS&HALL New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FALLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION PRESENTED: Approved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commissi Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning&Development for more information. A w BP-2006-1386 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2006-1386 Project# JS-2006-2055 Est.Cost: $13000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 11107.80 Owner: OLANDER REBECCA F&JONATHAN zoning:URB Applicant: OLANDER REBECCA F & JONATHAN AT. 96 CHESTNUT ST Applicant Address: Phone: Insurance: 96 CHESTNUT ST (413) 586-2376 O FLORENCEMA01062 ISSUED ON.612612006 0:00.00 TO PERFORM THE FOLLOWING WORK.SHEETROCK & INSULATE 3 ROOMS & HALL 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 6/26/2006 0:00:00 $60.001180 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 44A)II 96 CHESTNUT ST BP-2006-1386 GIS#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 17C-086 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category BUILDING PERMIT Permit# BP-2006-1386 Project# JS-2006-2055 Est. Cost: $13000.00 Fee: $60.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq ft.): 11107.80 Owner: OLANDER REBECCA F&JONATHAN Zoning IR8 Ap lPU icant_OLANDE_R REBECCA F & JONATHAN Applicant Address: Phone: Insurance: 96 CHESTNUT ST (413) 586-2376 (� FLORENCEMA01062 ISSUED ON:612612006 0:00:00 TO PERFORM THE FOLLOWING WORK:SHEETROCK & INSULATE 3 ROOMS & HALL 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: p� 4 House# Foundation: $la e640#trx r:veway Final: Final: Final: 7,;S"-®7 g �c Rou h Frame:�h✓ §2 P A—v Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: -(,? Final: Smoke: Final: g_a© 7 THIS PERMIT MAY BE REVOKED BY THE C TY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATI aNS. Certificate of Occupancy _ Signature: _ FeeT),ue: Date P id: Amount: Building 6/26/2006 0:00:00 $60.001180 212 A11in Sheet, Ph(me(413)587-1240,Fax: (413)587-1272 ]3uildin(Conanissioner-imthony Palillo