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17C-118 (2) O¢•CH�P�� _Grif-y of Xarf4a1nVtvu z r �855$CIt1TSttt! - DEPARTMENT OF BUILDINIG INSPECTIONS / INSPECTOR 212 Main Street • Municipal Building ' Northampton,MA 01060 r 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 bey a one or two fame y - 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 ftgulations. 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. (H a owner/resident's signs re requesting exemption) I will c 11 to schedule all required b lding inspections necessary for the building permit issued to me. Date Address of work location r I F E (riff of �,Tc flIzallip!oil Q y -qIi1a AChntfttD - _ d DEPARTMENT OP DUIL.DDIG INSPECTIOIJS 212 Main Street ' INZunicipal Building Northampton, class. 01060 WORICER'S COIATENSA'aON INSURANCE A17Ii'I A.%r1-j' (Iiccn Pcrmiltcc) a principal placz of businessfresidence at: ----- (sires c/d ty/7la1r,a P) do hereby certifjr, under thc.painS and penalties of pcl3ury, : SECTION 8-CONSTRUCTION SER,ViCES f 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature - Telephone 9 rnse; iabro eniercTratra tx Not Applicable ❑ c r-rtA, < CcvzP 4q yci't a*t'. CV it 3o 23 Company Name Registration Num er -- -- // (. Ao<-4c 0 rrF5 6 - 47 ).a0 b Address Expiration Date /J�}rRi/r�i M r�o i✓ ! �- Telephone AFFIDAVT M. L . 5 ,§SECTION 1D-WORKERS'COMPENSATION INSURANCE: 25C(fr)) Workers Compensation Insurance affidavit must be completed and submitted with this application.Failure to provide this affidavit wilt 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,St d in Laws and State of Massachusetts General Laws Annotated. Homeowner Signature F0 112!2 r i r, SECTION°5-DESCRIPTION OP PROPOSED WORK(check all-applicable) New House Addition ET: Replacement Windows Alteration(s) Roofing ' Or Doors CI Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[E7] Other[E7] ref Description of Proposed 5'41,0 £X )5 i-1 11j — 0 Work: 4:4,4-y Alteration of existing bedroom Yes L'/ No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa .WA, ouse �' as a�'dl#tea ` xistinc€ ioasing:.coritple# th Ti wang. 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-OWNER AUTHORIZATION= EI WHEN .OWNERS.Ad8I4T OR CONTRACTOR APPLIES<FQR Bu1LDING-PERMIT-' I as Owner of the subject property hereby authorize 0,11,I © C-1 ✓�✓>)L to act in 7a_�behalf, in all matters relative to work authorized by this building permit application. Signat r of Owner Date I, P-9Vt 0A ,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. I Signed under the pains and penalties of perjury. � 'i0 GL_ Print Name c Y y Signature of Owner/ gent• Date Section 4. ZONING All Informatioh 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 ; Il. i Setbacks Front �( Side L R:= i L: R:I i Rear Building Height Bldg.Square Footage i % Open Space Footage % t a (Lot area minus bldg&paved k .8 oarkine #of Parking Spaces — ;------i Fill: j (volume,&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW 0 YES 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 �i Page. and/or Document#i B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 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: 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 i IF YES,then a Northampton Storm Water Management Permit from the DPW is required. r City of Northampton Building Department 212 Main Street Room 100 Northampton;AMA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING C SECTION 1 -SITE.IN FO RMA IO TN - �-x �� section to be completed by office 1.1 Property Address: a Pr N L' L mot r Unit w m E Overlay Distract . � �^�'• ,.rn a CBMDIStnCt SECTION 2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: 3-9:A TyM EMiizk� ib rjtjFF, 4E-LA (. ►4tic Name(P'nt) Current Mailing Address: ss �i ys59 Telephone Signature 2.2 Authorized Agent: 1L 1" i(b (•�ClC itl A-i� 1 t 1�f� I J Name(Pri -- - Current Mailing Address: �_1�4, y 3 Signature Telephone SECTION 3-ESTIMATED°CONSTRUCTION'COSTS Item - Estimated Cost(Dollars)to be Official Use Only com leted by ermit applicant Building (a)Building Permit Fee 2. Electrical (ti}Estimated Total Cost of Constriction from 6" 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number Tlis'Section For Official Use Only Building Permit Number' Issued: Signature: i Building Commissioner/Inspectorof'Buildings Date 16 SHEFFIELD LANE BP-2005-0434 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C- 118 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-2005-0434 Project# JS-2005-0575 Est.Cost: $4800.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor:• License: Use Group: David Clark 143023 Lot Size(sg. ft.): 20429.64 Owner: SHEFFIELD NOMINEE TRUST Zoning_URB Applicant: David Clark AT: 16 SHEFFIELD i.X E Applicant Address: Phone: Insurance: 116 Rockland Hgts (413) 586-4347 NORTHAMPTONMA01060 ISSUED ON.10113104 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: ;b Rough: Oil: Insulation: Final: Smoke: Finai: OX THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATION Certificate Of OCCupanC�/ Si nature: ' FeeType: Receipt No: Date Paid: Check No: Amount: Building 10/13/04 0:00:00 3835 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo