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17C-118 (3) Alte Board of Building Regulat ons and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Reqistration: 143023 Type: Individual Expiration: 6/9/2006 DAVID M. CLARK DAVID CLARK 116 ROCKLAND HEIGHTS RD. ---- - NORTHAMPTON, MA 01060 ---- ------ --------- Update Address and return card.Mark reason for Chang SOM-04/04-G101216 DPS-CAl 0 Address [] Renewal Employment Lost Card Board of Building Regulations and Standards License or registration valid for individul use only -- a HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 143023 Board of Building ReguIajjqA&a&d Standards One Ashburton Plac m 1301 Expiration: 6/9!2006 Type: Individual Bost 0210 DAVID M.CLARK DAVID CLARK 116 ROCKLAND HEIGHTS RD. NORTHAMPTON,MA 01060 Administrator PVot vali :wi out signature -\ AXe Ql) _ Board of BuildiA Regulations One Ashburton ce, Rm 1301 Boston, Ma 02108-1618 License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 11/06/1951 Number: CS 000635 Expires: 11/06/2006 Restricted To: 00 DAVID M CLARK 116 ROCKLAND H TS NORTHAMPTON, M omvrreoruls o �.��,a�JOCU�zLUietla BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Q Number: CS 000635 aceipt and change of address notification. DPS-CA1 0 50M-04/04-G101216 Birthdate: 11106/1951 Expires: 11/06/2006 Tr. no: 4329.0 Restricted: 00 DAVID M CLARK 116 ROCKLAND HTS G� NORTHAMPTON, MA 01060 Commissioner � � j�Isasxcl�useffs DEPARTMENT OF BUILDING INSPECTIONS /= INSPECTOR 212 Main S tree[ • Municipal B uilding Nortiumipwn, MA 01060 r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to act as hds/her construction sup":-,'.0 s0r. 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 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�ui1 mg department for tie City of Northampton wants arty 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 f egulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footines (before backfill), s_onotube 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 pa v,p o•:-vrak understand the above. ome owner/resident's signature requesting exemption) I will call to schedule all required building inspections necessary for the building permit - issued to me Date �v • , � of Address of work /'4 S 14 e F r tg''-0 L /A A)6- location �r_o►'ZEtj ' fiO �Oy E 0—ii� Qf ��rfl�allt��Dll A f g3caswc!)acctta' — j o DEPA.RTMEIJT OP BUILDrt�C INSPPCTION's - 212 Main Street ' Municipal Building Northampton, A�ass. 01060 WORICEIZ'S COI'Q'ENSATION ClSURA CE A17FD) vrr -- A40 i�- -- ',� (lic�sxJperm;crcc) vrILh a principal place of business/residence at: -- 1I CQ P- 6 L-A+ D H-r5 {Q0- I if-A M P T-©N PA Ar- n ft o (phone-') q13 Y96 93 q7 (sa-�t/ci t-J lsla.ul a p) do hereby certify, under the.p?-=' and penalties of per7ur7, hat 1 i ( ) I am an employer providing Lie following V,'OfkCi✓s comocnsado, cove-Sc L In}' ecuplovecs wortang on ti)is job: (I:stir�c Coarz•) (Pelie:Nu�bcr) _ ( :pir�tior.DzL) I O I am a sole proprietor, general contractor or homeowner (c cie one) and Dave hired the consacigrs listed below who have the 'oleowing workers comoer_sa ion pokies: (Namc Oi Co:'�:nctor) (InSUranc.; CoinolrIV-Pouc NIUTrC-) (.Xpirauon bale) (Name of Conmaor) Cbls-Jranec Como_anwPoUcc; \! umi:-:t) (E•»irrdon Date) I (Name of Coa= C-10 ) (Insuranc- Compan}"/Foli(:)" Number) (Expimdoa Daic) i (Name of Concracor) (Insurance CompaayNoticy Numb-:r) (—Expimdoa Dala). (An—h ad4szoca1 6cC.ifaceesL v to a c!v iaformiioa '• perta,a:ag to.Il a�_r_.o�) - I, . I am-a sole proprietor and have no one woridj)g for me. ( ) I aai,a home owner performing ail the work myself. NOTE:plcsc be zw-=on.-'bill bcl= o M=ItIo ctaploy pct.otn to do*--:•-• cs rim c rcpma•••uric on a d%---LL--f,of not mace 1 t_sr tmi r is ubEicb the bomoowmoc reed=or oa Lb.p-ars6:ypur-L a-c=the-...n tz ox C=.rlly to be cz>ploycs uaG-the wui ct Fuca Aa(GUI 52 s 1(3)).=pptir6an by a bomco -=ra c lie:a pcmit n_y c idmcc the lc-Pr—of d.Waded=C..P.s A&- I uade,z.ad rb.a a°OPY of tbu mecum az.y b.foco.vded to th.DtmOOa of In�LrriJ ncodea. Oboe of L=�for th. cove-r.Sc rcifie:sioa ttad t!t_t Ciltae to ccrouz tovR uadc sociioa 23 A or MGL 132 m Irk to the i=p=x tioa of eimicA pca 16c= coast=.mg of i riot or up to S }00.00.nUor or up to occ ycr Lod civU pmAY.ia in tSc rorrn or.Stop Wort Ordc Lad. FI=of S 100.00 L d_y tpi=me for dcp.:-cL�1 u,c OMIT Permit Numtic — Si�naturc of Lic sr_ --- SECTION 8-CONSTRUCTION SERVICES- "I 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: t)R\! i J) License Number l i d Q s 1—K L AM-0 Nt i 5 I Nc r►+�M P TtIQ I1 bb � n6 Addr p i O b 0 Expiration Date Signat re Telephone V i 3 sgG, Y3 Y 9lte°isierecoire Crii° o eiearit acfa" -00 .` Not Applicable ❑ P 'J p CL rA-Allo( ------ Company Name Registration Num er t L! OCS V<L41,J D T'S 11J 0-&-TH A Tb-'J b I t w I Q Address O t O too Expiration Date Telephone S86 43LO SECTION 10-WORKERS'COMPENSATION.INSURANCE:AFFIDAVIT"(M.G,.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.......`` 6 No...... ❑ 4> 1 U 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 Gable 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,Stat d Local ng a sand State of G eneral Laws Annotated. - Homeowner Signature cvwu n4tA� r SECTION 5-DESCRIPTION=OF PROPOSED WORK(check all applicable) New House ❑ Addition ; Replacement Windows Alteration(s) ' Roofing Or Doors ;R� Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[p] Other[O] Brief Description of Proposed ADpt �a 1NCke.n.-s e r4� R 0)2-F- /r�CRe-0-Se 13AT-H . 12� ra�va Work: C r-LL Q STA I P, W+A`I' P,-e,0,b\1 E YI S-t. CT LL A t1 A N D AT 1'tc '51 4 I Q3 LG'� aA�'t. ��ricP�eF�tfiLa� n .,xG Gc*tCrtr�t Alteration of existing bedroom Yes No Adding new bedroom Yes _ No . Attached Narrative y'�-- Renovating unfinished basement Yes No Plans Attached Roll e4et �1 N S kiLg To)H oN 'LX 15T CDNC.V) 14� L5, 6a �i��l�e�:.�ous���d{ac �c�tataxr�tlac��ia�slna:�,eo�p�e��t� '�[Oa�l�g: a. Use of building:One Family Family - Other_ b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? Y G5 ` 4e xI5-r as d. Proposed Square footage of new construction. 11B Flo Dimensions e. Number of stories? 1 1 > x+ x+N �P! IN Na f. Method of heating? � ) � R I lb F Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction W 0 0 R (s A r ►En i C t-�JC f�CT< I3 L P C V f..e J s..'G rk T I ,-A'A i. Is construction within 100 ft.of wetlands? Yes _ No. Is construction within 100 yr. floodplain Yes X, No SuD17`-- L B Y A 9 0 j. Depth of basement or cellar floor below finished grade ! 'pj? 1"f t +W t IL HAVE wtA-k<-to-r D Do R k. Will building conform to the Building and Zoning regulations? Yes No. I. Septic Tank R City Sewer Private well City water Supply X SECTION 7a-OWNER AUTHORIZATION,=TO BE COMPLETED,WHEN OWNERS AGENTORCONTRACTORAPPdtt$FOR BUILDfNGPERMIT I, D AU t D C t-h ky, as Owner of the subject property hereby author' to act on my b!�I re lative to wor uthorized by this building permit application. Id1 �/ � ' Signature of Owner Date I, t D Ct oy�`K 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. 7 �i C i._•i� Print Name IUi� - r✓S Signature of O er! gent Date � *+ . Ai�C,''r/ oJ Section 4. ZONING All Informati6h 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 iD Setbacks Front Rear Building Height F�fl Bldg. Square Footage 010 IEE 7­7 ._ . . ' . - , r Open Space Footage ~- ' L/0 o ^^ x' q� -----------' —� �Z ��� ^- -- ~/oL� A. Has u| Perm it/Vuhonue/Fndi ever been �suedfor/on the she? _ ^ N"' DON70VOVV ^r~� YES »�� - ~� -- IF YES, date issued: ~~- -- IF YES: Was the permit recorded at the Registry orDeeds? �� NO �� DON7 VV KNO YES IF YES: enter Book Page and/or Document# ' x~�` �~� B. Does the site contain o brook, body of water orwetlands? NO VV �~�DON7NND YES �_� IF YES, has permit been nr need tn be obtained from the Conservation Commission? ' Needs tobmo'—~~�^ x=� 0bta�x�d v~� Date�ssumd� ��"'=° v�� ^ �,� ' ' x~� ./ C. Do any signs exist on the prupar�? YES �~� NO IF YES, describe size, type and location: | D. Are there any proposed changes to or additions of intended for property? YES x�� NO �J�r - ~~� �~ IF YES, describe size, type and location: v E grading filling 1 acre or is it part ofa common plan �0� \Tl8w that will disturb over 1oore? YES � NO �� Uu'�� �i�TU{\R AR�� � �/ g ' � ��u - ���L�A(\ Y»LE ^ |F YES,then a Northampton Storm Water Management Permit from the DPW is required. � , n - City of Northampton Building Department biavua, 212 Main Street ` err ili �r Room 100 Northampton; MA 01060 its tan phone 413-587-1240 Fax 413-587-1272 Ptou te° 22 110141_Jlll APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING 1.SECTION 1 -SITE,INFO ATION RM Tftis section to be eampfetecf by office 1.1 Property Address: Unrt n - _ Z e} Overlay U�strrct +-U 2 w C r,_, Dist is r CB DGSt�c SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: DAVky CLARK ilb ADCK(Lr)Np KEI6-HI-S Name(Print) Current Mailing Address:EEL, A:H AN F`110 0 MA 01 NPC Signature Telephone LI( 3 E EL, N 397 2.2 Authorized Agent: p ray l � G t-Ps tt�C � I, b Q c,°-c.« c, q.�►o ►►�S - Name(Print) Current Mailing Address: f6c A-T!i PAM P Ta,4 M C t 4s C Signature Telephone t 54 L(3 it 7 SECTION 3­ESTIMATED;CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building (a)Building Permit Fee ,.,o:✓ I� >tJ�a 2. Electrical ,. (b)Estimated Total Cost of - ^ Construction from 6 3. Plumbing ^ k s Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection - -- 6. Total=(1 +2+3+4+5) e " '`' Check Number This Section For Official Use Only Date Building Permit Number Issued: Signature: i Building Commissioner/Inspector of Buildings Date