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17A-150 gtL'►MP�. , ..Gxfy oorttlittIrt _ � �11854ACh3LStIfB - DEPARTMENT OF BUILDI3\TG INSPECTIONS /= INSPECTOR '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 his/her construction super , ;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 farm 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 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. (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 i �0 tUCr3�c�T0 t F =E CrLZI ITf TC7rf lIzallip1Dl_l -Rla3aitchnrclla• _ DEPARTMEI-T OP DUILDo\ic INSPECTIONS 212 Main Strcct ' Municipal Building I Northampton, Mass. 01060 WOMG:IZ'S COMTENSATION LNSURA-.NCE AFFIDt, tvrr 1 J o ,..� v'rith a principal plac. ol7businessfresidence at: -- -- (phoney-) °l cl do hereby cerdf--, under thc.painS and penalties ofperJury , hat i I (�I a m an employer providing the following!%vorkcr's compcns-nno, cove age for Im etuplovecs worUng on this job: L Z o6' Omni an=Co,Eira ,) (Polio:Nu-ter) (� irvo,Dam) O I am a sole proprietor, general contractor or homeowner (ccie one) and have hired t_he con-actors Listed below vvbo have the folloivinP, Worker's comnen_sadon aakies: (,Namc Oi Co tncior) (IRRraI1c COII]p11]}'yPGUCi �r11II1�C:) \J11.1U0R l�1lC} (Name of Coorraaor) (1nSaranc". Compa yiPolin, `uncrr) (EaDirz6on Date) (Name of Cona-acrar) Onswancz Compan}•/Polio• Namb-.r) (Expirdoo Dalc) (Name of Contactor) (Ln_surancc- ComraaylPolicy Numbs) (Expiratip❑Date)_ (attach coca!t'tcC,ifaccaa�•to it 3u<ic iarormaaoo pcta.iaias to all O I am a sole proprietor and have no one working for me. ( ) I atn.a home owner performing all the work myself. NOTE:plea be evrir=tt,.K{,G µLCT]Kbp a�piay pC2QCS LA dJ C'rt nh =,j=,o r rcaa Kock on of noc moot%h--c ttsco eta in the botnoownc rvado or oa the Qounc,z,purtcn a tb,aW c z ooc C.--a .1}y ocrid cod w be eitploye�ury a the K, 1-...X."iioa Aa(GL152-n l(S)),=gpUcL6cc try•bommaaa fcr a lice=a pamh ray—d-noe the lc�1 n»,.of nz-=ployx uador d.-Woc{cofc Cooap,_j;oo AcL I uodcstaad tisa a copy of tbi,mtcmcm m.y be foci nrdnd to tba Dop,ctmcot of 1 6. .ic1 Aoadcatf OE—of(c:=ur.00n foc tb. eova ase vtTjf pyoa Am OL-A L-i%zc to gcc, =tovecage trod=section 23 A of MOL 152 eia led to the impcu oa of eimia:d p=naltia ooaur m or ?Lp�j�c:a o an&oc;x p�of up to ooc yc�t cad cull prnahia is 6c form of a stop Work Ocdc cad a rim of S 100- a For lv(JP.—_ Lot ° Signature of Licroscc/Pccmiucc e SECTION 8-CONSTRUCTION SERVICES r 81 Licensed Construction supervisor: Not Applicabllee�❑ G y Name of License Holder: JC)*1A /�tL�-tl�•p to t U 1 License Number 3 S AL-t4 t O l L ti 1 D Address Expiration r to Signature Telephone 6cs'-5�5 � •• , eais`tered koine'imp rieir ant di tradf°o Not Applicable ❑ ( nac�C� `i Company Name Registration Num e— e ------ AC.k-AQ , Address C -j Expirat' n D e ,- V- ) V%,z-L W.-CQ K-Or- Telephone v SECTION 10-WORKERS'COMPENSATIOU,INSURANCE AFFIDAVFT(M.G:L,c..152,,J'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-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 r Y � SECTION 5-DESCRIPTION OF PROPOSED W.ORK(check all applicable) New House [] Addition ❑:, Replacement Windows Alteration(s) Roofing Or Doors ©© Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [NZ' Siding[0j Other(pj Brief Description of Proposed work„NF- Rbof. LX4140 436 � I Tr-*- hJ 'arrrA s . ADD art cks �,D c.,�4R,eux Alteration of existing bedroom Yes___�Z No Adding new bedroom Yes y No . Attached Narrative Renovating unfinished basement Yes _ �No Plans Attached Roll -Sheet sa�f�(e��a�tse:�and4ci.��di#eta e�lsti��c��t�sincr�co�atetrwtlie�aCn : 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? GA�,AslatT : �S L SF d. Proposed Square footage of new construction. KOA4,,q itUc• 3 cn, Dimensions�M` cwr e. Number of stories? Z- Zj�'tC�C t+'(0 f. Method of heating? &*s t7 aT A« Fireplaces or Woodstoves '� Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction W 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 S k. Will building conform to the Building and Zoning regulations? Yes No. 1. Septic Tank City Sewer_ Private well City water Supply V SECTION 7a-OWNER AUTHORIZATION r.”TO,BE COMPLETED,WHEN, OWNERS AGENT OR CONTRACTOR APPLIES FOR iBUILDING PERMIT I, gf4 S as Owner of the subject property V o hereby authorize 0 a �O to act on my behalf,in ers relative to work authorized by)his building permit application. J 3 a Signature of Owner Date I,_ C'%VA b1 . �I�GWR-RM ,as Owner/Authorized Agent hereby declare that the statem and information on the foregoing application are true and accurate,to the best of my knowledge and belief. Signed under the pains and enalties of perjury. Print N e Signature of Owner/Agent T 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 too Setbacks Front ERT Side L R:' L:1J 11 R:aii], IK Rear — Building '� --- - g Hei t I 2L i Z ZI _ ._..._ Bldg. Square Footage V 0". —t � Y Y 4•� f I.�1,� 113 Open Space Footage % (Lot area minus bldg&paved parking), i #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? N0 Q DONT KNOW YES 0 IF YES, date issued:" i IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page; and/or Document# B. Does the site contain a brook, body of water or wetlands? NO a DONT KNOW 0 YES Q 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 IF YES, describe size, type and location: L D. Are there any proposed changes to or additions of signs intended for the property? YES NO IF YES, describe size, type and location: s j E. Will the construction activity disturb(clearing,grading,ex9avation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES P NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. City pf Nortompton tji ding Department Wit° 212 Main Street St wef e tl _ 1.0 Room 0 - r�e M North"alnpton; MA 01060 r pindA 3-587-1 40 Fax 413-587-1272 foSan AP LlCATiQN TO L'CSI $TRUCL ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION t= ITE'INFORMATION This section to be comptetecf-by office ` 1.1 Property Address: 44 �F4- VAcYZtAs �! M T Lo�,�C_/t. 1 A Zone Overlay D�strtct' Efin St D�str�cf C@ D�stnct . SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(Print) � Current Mailing Address: "113. 156 - 6t/�.n.l Telephone Signature 2.2 Authorized Agent: J o" &cX 11 t 3 S 1titl�l r.1 S► S�r.►�or ��- , tylA Name(Print) Current Mailing Address: "k t 3 - (o (o S • !i Signature Telephone SECTION 3-ESTIMATED-CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building -(a)Building Permit Fee 5-1 aOb 2. Electrical .(b)Estimated Total Cost of $ a (50 n Construction from 6 3. Plumbing dV Building Permit Fee d 4. Mechanical(HVAC) 5. Fire Protection d 6C) 6. Total=(1 +2+3+4+5) Check Number 14 9 s This"Section For Official"Use Onl Date: , Building P t N ber. Issued Signature: Building Commissioner/inspector of Buildings- Date File#BP-2005-0681 APPLICANT/CONTACT PERSON Sackrey Construction ADDRESS/PHONE 83 SOUTH MAIN ST SUNDERLAND (413)665-9995 Q PROPERTY LOCATION 44 FOX FARMS RD MAP 17A PARCEL 150 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid XDO 70 T_yueof Construction:_RENOVATE KITCHEN,BATH,ADD DECKS&CARPORT,REROOF& REPLACEMENT WINDOWS New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 040714 3 sets of Plans/Plot Plan THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9RMATION 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 S t Commission r z oo Signature of Building Otficial 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. BP-2005-0681 44 FOX FARMS RD GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A- 150 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UTJ REGISTERED CONTRACTORS Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Category: Permit##BP_2005-0681 Proiect# JS-2005-0924 Est. Cost: $93000.00 Fee: $395.00 PERMISSION IS HF,REBY GRANTED TO: Const. Class: Contractor: License: 40714 Use Group: Sackrey Construction 0 _ Lot Sizes . f�t. : 30317.76 Owner: SCHECHTER BARRY& Zoning: URA Applicant: Sackrey Construction AT: 44 FOX__FARMS RD Plr_one:_ Insurance:Applicant Address: Workers 83 SOUTH MAIN ST (413065=9999_5_A)__ --- Compensation. SUNDERLANDMA01375 ISSUED ON:1 15 105 0:00:00 TO PERFORM THE FOLLOWING WORK.-RENOVATE KITCHEN, BATH, ADD DECKS & CARPORT, REROOF & REPLACEMENT WINDOWS POST THIS CARD SO IT IS_VISIBLE FROM THE S_'CREET Building inspector Inspector of Plumbing Inspector of Wiring D.P.W. - Meter: Service- Footings: � Foundation: Rough: `�� House# Rough: veway Final: Fival:, �j �� CFinal: ��� - Rough Frante:0 3'7'©5/� V — �-faL Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: -J 114=0iv J4 Final: U i� 10 2 7 �� L 0 J 1'3 Final: f-6'C)S� Hoke: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTI'AMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of_ OCCUf�anC s�unatnr2. FeeT ►fie: Receipt No: Date Piiid:__y____ Check No_ Amount: Building 1/5/05 0:00:00 2285 $395.00 212 Main Street,Phone(413)587--1240, Fax: (413)587-1272 Building Commissioner-Anthony Patillo