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11C-017 (2)
$ � �GlassachTTSeffs DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municipal Building '>o Northampton, MA 01060 5 r 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 supc:-:6,sor. T he state defines"Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two famiYy 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 0gulations. The inspection process requires that the building department be called to inspect work at various stages, which include foundation/footings (before baekfill), 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 f'' f f, I, r'117) understand the above. (Home ow r res' ent's sign ure requesting exemption) I will call to sche ule all required building inspections necessary for the building permit issued to me. Date C/ C Address of work location r � aIttA}Ipr ��frl;fl�i�111}lfDl.l — �R�asakcflncc11is' _ _= DEPARTMENT OP DUIIDI\IC INSPECTIONS 212 plain Strcct Munlclpa! Building ltorthampton, Mass. 01000 I `�'ORICEIt'S COIN NENS TZOlei LeiSURAJNCF- AFIUAVI-I- l f I __. .. ....._-.-.--- �>oth a principal place of businesslresidence at: i (phone:') (sa=kki tylaztc fri p) do hereby certify, under the.pa.itLS and penalties of perjury:, h2i j ( ) I atn an employer providing the followinu6vorker's comoensado, cove Mee for 11)), IIi emplovccs worl3ng on ties job: I (Iamran=Comrz-M, (Poticr i:tl_mir_r) (r:pircior, Date,) i - j O I am a sole proprietor, general contractor or homeow-Der(c cie one) and have hired j the contractors listed below 7-rbo have the folio%vine workees comnenurion policies: I � (i`alnc of Co�...._ccor) (Inns-snc;c Cotnpin}it ctic, •) 1 — (Name of ConCctor) (Lns-,u=cc Comoanv/Polim- Numb-cr) (—B-pir,:oon Date) (Name of Cotlrraetor) (Laurance Comtey/PoUcy N-amber) (Exp'Lm6on Date) i (Name of Contractor) Rosurancc Comczl y/PoLicy Numb,r) (Expuation Daft). (ntIUj]�i::ocaJ c'ccs.if cco�3,ry to c�c'vc�iafocmi-ioa p�ninia6 to.it ooxr-t.o�) - O I am 'a sole proprietor and bave no oat woridng for me. (� I am.a home owner performing all the work myself. NOTE:plese be awxm d-w wlate to c=plcy pcsam to dz—,jn= =e,on r rgau—or;-oa a d,- --;:of ON MC-Lb--LX--rmia im WS6 the bomo ,=-rmido or oa the aouac4,ap�tbeao r sac rJty oecrd= d to be employe-z unCc the---kc.{s c=pc=:- Oa Act(GLtl 52-n 1(5)). .pplinlAon try a bommaaa fcr a lice.or permit m:y�id�oc ebe Icp.l n_^,•of=q-,toys under dae Worked.Cocmp..Ljoa Art c,�naa,aand tha a oopy of a> .mt.-ma=n,ay be foc+arded a the Dcqu,axaa A—d.&OM—or G.-ror the oovcagc`r xZcaioa&nd Uu f_itrac scwrc'covcnt9c under IOC 60m 23 A of l.(OL 132 oa tcd to the imPo:¢6w of c•imimsl p—W- of a oCup oCup to ooc yr-V end CCU pmaY,io is be form of a Stop Wort;Ord-amd a ( o(S I0'-oo a dey ap iaA me Foe dep."!,— use only Pcr n t Numlxr _4 J I,�p. Lot K R. Sign t �f i c t, e __ SECTION 8,CONSTRUCTION,SERVICES t 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone IRentsferldrn�p me nn Not Applicable ❑ Company Name Registration Num a—fi�------ - - Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE.AFFIDAYIT(M:GcL. 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"homeowne ' certi and assumes re i 1' for compliance with the State Building Code,City of Northampton Ordinances,S ate and Lo 1 Zo ' ws of Massachusetts General Laws Annotated. Homeowner Signature r 'SECTION 5 DESCRIPTION-OF-PROPOSED.W.ORK(check•all°applicable)' New House [] Addition [❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors F-1 Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0] Other[C�l Brief Work:Description of Proposed 'Sri-j f ' Pb W O /WQ Rc S 141 1"J AIC.- Alteration of existing bedroom Yes No Adding new bedroom Yes K No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa iNevl€ house anta.:-xistin mpletethe o ta`iung: 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,,OWNERAUTHORIZAT16N=TO BE COMPLETED:WHEN OWNERS AGENT;OR CONTRACTOR'APPLIES FORsBIJ]LDING�PERIVIIT 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 1 ,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 penal77/7 Pri Name /U y 7 a Signatu f er ent z Dat 1 1W Section 4. ZONING All Informatibti 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 3 Frontage i ' € Setbacks Front Side L: R:! i 'L:' R:i E � Rear I Building Height ----- ------ U ' J Bldg.Square Footage % r-- Open Space Footage % r--{ (Lot area minus bldg&paved parking) #of Parking Spaces Fill: l �- volume,&Location)— A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW Q YES 0 IF YES, date issued:! I IF YES: Was the permit recorded at the Registry of Deeds? NO 1 DONT KNOW 0 YES 0 IF YES: enter Book 1 Page! and/or Document#g B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained 0 Obtained ® , Date Issued: j 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 0 NO 0 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. City of NorWampton Building Department 212 Main Street x Room 100 Northampton; MA 01060 i phone 413-587-1240 Fax 413-587-1272 " APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -.SITE,INFORMATION This section�be co 1.1 Property Address: d Y+ x (� 5 ©/ (,�S 3 Zone° Overlay Oistnct M ; Elm SyD�str�ct GCB kDistnct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: J05fxft D. N14C- 5 r LC�")S t1j/4 oloS 3 Nam (Print) Current ailing Address: 177� Teleph e Signature 2.2 Au on d A ent: Name(Print) Current Mailing Address: Signature Telephone SECTION I-ESTIMATED•CONS-TRUCTION 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=(1 +2+3+4+5) Check°Number ✓ This.`Sectit n For'Off dial Use Only' Date,., Building'Perrnit Number.` :Issued: ' Signature: Building Commissioner/inspector of Buildings Date l BERNACHE ST BP-2005-0355 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: I IC-017 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-2005-0355 Project# JS-2005-0473 Est.Cost: $1500.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sa. ft.): 8755.56 Owner: ASHTON JOSEPH D Zoning:URA Applicant: ASHTON JOSEPH D AT. 1 BERNACHE ST Applicant Address: Phone: Insurance: 1 BERNACHE ST O 584-1676 O LEEDSMA01053 ISSUED ON:9127104 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 Occupant Signature: FeeType• Receipt No: Date Paid: Check No: Amount: Building 9/27/04 0:00:00 20065 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo