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17C-115 �TtL MA �$0 Crzt-r of Nort aillpteril Z �1855AC}�IISCtt4 '^1 DEPARTMENT OF BUILDING INSPECTIONS /= 212 Main Street • Municipal Building INSPECTOR Northampton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as !-:is/her construction sups: . .S;or. The stale 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 occupancv 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 E rlcsanchnsrllc =- �, DEPA-RTME1JT OP BUILDING INSPPc7jc)?S — 212 Alain Street Municipal Building Northampton, Mass. 01000 VYORICER'S CO'MTENSA770N •MSU>RA-NCF AF=AVIT insx/perm� %vILh a principal place of business/residence at: (aTr�t/ci i}/sutL/a p) do hereby cerrifj-, under Lhc.pa-ins and penalties of penury, .hit ( ) I am an employer providing tdie following %vorher's colnocnsa:Jon cove ale for Iny etuplovccs NvOrlDng on this job: Onsu-r-an=Conr.`cy) (POEC-: >;u.mbcr) --- (E:-pir-a or, Dom) ( ) I am a sole proprietor, genera] contractor or homeowner (CI C:c one) aid have hired the cones ac',oFs bsted below wbo h2ve- the folio%vInQ Worker's coOE]pt cation pc!!cies: (i+fllI)C Ui Co."::L i1) Orlsur311c'z COIT193J1-'/Pouci 1�`umcc:) rt'-'-i)fida0i? I�:IIC) (N:me of Conuacor) Ras-j aoc:z Comaati•/Po!icr Date) (Name of ro=an;) ( a uraacc Compan)•/Pcug- (EXpirrion Date) Ttamc of•COnLTactor t (insucan� Comc=y/PoLicj lNumt, ;;, (E1pif don Data. c�1O to mC?ud�u'Jo"-i oa p.�a.inins tv.11 -_r_.o:s) j C { am a sole proprietor and have no one wor�g for me. I am.a home owner performing all the work myself. NOTE:plcs be cwa e chi wl�)e lxmeo e,m vt,e�Icy pee to do n c euao c rc-,�u wane ov.d..ell^z of ant Mort t—tsv=r,,is lc�.rj ibe bomootwcc raid'or oo Lt'pout zp?an =--t--Co Doc acn,--uy oc—:d-od w be —TIOy—uadc US- aScf:r - ., AA GL15Zn I 5 t ( )�=,Pliri6oa by a 6rnncoava Icr_br.�_or pc-mn ray c.-rdcxc tic Icgl ctaau of co—P,-Yor undo d--Worti<!a C.oa=pomaiion Au- [ua6c-11y d the>Dopy.(at:.mt.—_j—y b<f«--__4-d to Lb. of In��szicr/,cc�d �Off o0 of G-�for tb,e oova�4;'c vIf c=1ioo,--td Uu L-ihzc w amtrc tovcrtsc uadc'=j o 25A of t.toL 152 cw 1, to be a�oa of c miaL l pco-16'= —i=..i'zg oft rise of up to S 1500.00 a1 ''0c of up to ooc yr-r cad c,i pm>tia w t)c form of a S..op W orb Ordc end a Ct=of s 100.00 a d--y a�iIIA For dcp.rtn�'��uc ony PL-r=1 NLLMIJC' —�—� (�• u -of ic=lsct/perrn-iUcC -_ SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9. Recilsbi ` _ oire Imrovement Cont r y P Not Applicable ❑ C o m v an me Registration Number � ��� /6 s Address Expiration Date i'C y� �� •'[„� Telephone 1 SECTION 10-WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M.G.L.c.1`52,§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...... ❑ 11 �.�ome=0vwner Exem` pno�i' 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 par_cel ofland 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 SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House [❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors C] Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [Oj Other[O] Brief Description of Proposed r Work: t Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet =He ad r..adton to m loW nn sa If New s d i e h 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 7a7-OWNER-AUTHORIZATION-TO BECOMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING.PER as Owner of the subject property hereby authorize ^'Y to act on my beha?in t elative to work au or ed by this building permit application. i Signature of Owner Date I as Owner/Authorized Agent hereb Feclare a t the stateme is informregoing application are true and accurate,to the best of my knowledge 7 ation on Ehe and belief. Signed un er the pains and penalties o rjury. Print Na fner/Agent Signature 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 Rear Building Height --7 Bldg. Square Footage Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has a Special Perm b/Vorunoe/Findi ever been issued for/on the site? NO 0 DON'T KNOW 0 YES \_/ IF YES, date issued:, IF YES: Was the permit recorded ut the Registry ofDeeds? NO [ ) DON7KNOYV YES �� IF YES: enter Book Page and/or Document#� �� �� �� B. Does the site contain abrook, body ofvvaterorwetlands? NO \�� D8N7KNOVV \�/ 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 proporty �� ��� YES \~� N0 \_/ r- ---- IF YES, describe size, type and location: | D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0 IF YE3, describe size. type and location: E. Will the construction activity disturb(clearing, g�ding un.or filling)over 1 acre orinhpa�ofa common plan that will disturb over 1 acne? YES [� ) NO � ) �� �� IF YES,then a Northampton Storm Water Management Permit from the DPW is required. Department.use"only City of Northampton Status of Permit Building Department Curb Crrt/Dn Permt �evua� 212 Main Street SewerlSepttCAvallabrlit}( Room 100 Water/Weli Ayailabilif}r° Northampton, MA 01060 Two Sets of Strpctura(1?lans phone 413-587-1240 Fax 413-587-1272 Plof/SitePlans OtherSpectfy APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: This section to be'cdmpleted"tiy"office Map Lot. Unit:.` Rorie ' Overlay Distcict Elm St.DistrictCB❑isfrtct` SECTION 2—PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: I G J�f Name(Print Current Mailing A dress: tfl/ Telephone Signature Je 2.2 Authorized A ent: Name(Pr k Current Mailing Address: Signatu e Telephone SECTI N 3-:ESTIMATED CONSTRUCTION COSTS 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 =0 +2+3 +4+5) Check Number This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date a, z . V U BP-2007-1258 GIS#: COMMONWEALTH OF MASSACHUSETTS 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-2007-1258 Project# JS-2007-002009 Est. Cost: $5000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: James Roberts 117154 Lot Size(sq. ft.): 13677.84 Owner: EGAN GERALD F&FRANCES Zoning: URB Applicant: James Roberts AT. 56 STILSON AVE Applicant Address: Phone: Insurance: 30 Edwards Rd (413) 527-6078 WESTHAMPTON MAO 1027 ISSUED ON:612512007 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 Signature: FeeType: Date Paid: Amount: Building 6/25/2007 0:00:00 $25.003118 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo