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17A-136 (2) O4Tl�1p�O Z � � ,�lassacl�nsetfe - e _ DEPARTMENT OF BUILDING INSPECTIONS /= INSPECTOR 212 Main Street • Municipal Building Northampton,MA 01060 ,N 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: 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 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 occupancy until the work can be 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 h 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 �-ttuN.I�TO - { C�11f1T -of Nartilcimpftill _ 6 fiIa>>xcftc:sctte' _ L>EPfit2ihfEA'-F OF DUILDDI G INSPECTIONS m 212 Main Street Municipal BUII(UIlg, Northampton, Mass. 01060 WORKER'S COMPENSATION I SURANO, A + + AV1T ��S �fl JAR- ?QjLD2A ' - - - ----- _-- - - _ (I1cCPS°_ `ICr:IlltiC^_) %vlth a principal place of business/rt,idence 7-7� d0 1lereby CCrillj', t?nClcl" the' paa1S :1iiQ 1"1C ii:a 1C`i (l( nCI]l11y, ill8i: { ) I am an empioyer providing the follo"vinz '.:orr_er`s collinensarion coven: c for In), elnployces wor�drlg on this job: v (La-7,L=cz: comp-am') c-c:Nuzrlbcr) (�r�. .iraon Date) ( ) I am a sole proonet_or, general c---�n-daC`or t!omeo (Circle one) and gave rrireti the contractors listed beiorr;;f;o 1 the Poll L:g rork,ers co pen on o! c cs: (Z`;ame of Continctor) (.ns,,�'nc Datc) (Name of Cont.'.cto:) (11-Lsur,_nc�: Compai y/Po!icI• N=bcr) (D.Pir Lion Date) (Name of Coancior) (II1Si 3I]C^ ( O i r'l�:i/1?OLc, NtuLr�:I) 'X; :nor Dal,-, (Name of Cont-imor) -- Gasaranc:. Comer_y/Polio Ntrmr,�-r) - (F;:r;: ion D ite)-) not Lmcc th--a thr-oo units in or oc: csyloycsur'6c tlr%V6:e:c {-_:_i a it (Gi:5�� '.(5);.-,.riic:;ic::by a hrmcowncr for: legal nanrr of an maQloyx vadcr tv�Wcv?<cr'�c:o.�.�;>a—Sion�_eL I unde.-Tta..ad Iflar i Deny of Ilia ttslc:s•r_vy F,o Ioru•cuc!rl to tl»IY_p-Lzx,-,:of IrKfL=-riel P.nil,.�:t�C1roo of ..r�-._o for tlx oovcra�c ifictioo aid t1 at f ilwc to rn uc mti-r M ur 3 <�.iM 2S.q of?.iGi.152 c n lc--d to tlw imposition of m- i:_1 pcc nL:a comisting of n ft:r of up to S 1 30U.CVJ aa1'cr ir.:nr:�r-^ti,1 of::p to cr. }- .:-.j civil xru2tia in is nn of a S!r,:';'cri-C?ti a:d a f t�of S 100.00 a d_y Kgztilml rn- . _ scar cScS% u.c cnty NIt it PermmL:r . --___-� I-- - -�� ------- - -- Si�naWr oY'I.icz:a_;c�JI'crm;ac:• - ---_T-.4:�--:•- SECTdONB GOT15 'RUCTION $ERVICES 8.1 Licensed Construction Supervisor: (� Not Applicable ❑ Name of License Holder : 1 Pt�L� �` 'J 6-74165- License Number 4-A t6 6, Addre s Expiration bate Signatu Telephone Re tere ornem r.:. acme °. ontr•.acto Not Applicable ❑ L-Ty—1Z75 13o .39 Company Name Registration Number Address Expiratioh Date Telephone SEC IDH3D WORKERS' COMP;ENSAT;ION iNS.URANGE AFFIDAVIT KG L -c 152, §!:2 C., i -:- 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 hue 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 aparcel 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 dwrllina affarherl nrdetach srr,�rtures�cc�ssory_to-su-c"sf--aad/oi£ar�—_ 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 15') (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 i I , . . SEGTiAIDSRfPTlfliVOTPROPOS DIIORK cMeckill a EJ i5l,cable New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing V Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ J Siding[ J Other [ ] Brief Description of Proposed Work: VN�7T(AL-- L-) Q(,H000 S05-A-7-24-W6 Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll O- Sheet❑ 5 'evu ous d�or �,taon4toe s�inhou ,n�; te��°o�l�.°w,n�: 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. bimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Mascheck 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 Nc 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 SECTI(3T�C111YNERAUT ©R.IZATIONil, TO BE COMPLETED W Eff,d OVifl�f�l~tS�4'�ENT�©f2��Ot�3,TRACTO�t�iPPLIESzFOR B�T1tD1NG'PERMIT _ . ... as Owner of the subject property hereby authorize to ac; or my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, �J �S �. S ��Ar � � vLiu), es 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 penal 'es of perjury. :Print:Name Signature of ner/Agent Date Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION I Existing Proposed Required by Zoning This column to be filled in by Building Department i Lot Size i Frontage Setbacks Front i Side L: R: L: R: Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) J #of Parking Spaces I Fill: (volume'&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO k�' DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 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 property? YES NO _ 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: - - ity(o� Northampton � i� lrig Department 212 Main Street MAY - 4 2004 ,Rpom 100 Northampton, MA 01060 4 phone 413-587-12450 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECnOR 1-SITE 3NFORMAnON. 1.1 Property Address: is section 6L gi o�p-eted by c►fNce ��(f S�•'/y Z�e '�`-���� ��. �.�'�1ierllaGjG D�St-n"ct���` � tnI15LTJC ` � SECTION.=2 PROPER 7X`01NNERSHIP/AUTHORIZED:�IGENT' 2.10 ner of Record: Name(Print) Current Mailing Addr S -gyef2.. Telephone Signature 2.2 Authorized Agent: 5-iamfs -D. 3DSZ 3�►c��RS (�C, , wl��el� . N►�, bio`�3 Name(P t) Current Mailing Add : S Zz�1--7 163 Signature Telephone SECTIONS-ESTIMATED'CONSTRUCTIotcoSTS Item Estimated Cost(Dollars)to be Offic�al;lise;Only completed by ermit applicant 1. Building =a) But[dng Perinit Fees' 2. Electrical of - .Construction fros•n` 5 . 3. Plumbing Budding Permit Fee; 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (I + 2 +3+4+ 5) GheckNUmb'er This Section:FOr:Official Use°Onl Building Permit Number: Date issued: Signature: Building Commissioner/Inspector of Buildings Date i i I �I i i i i ` •:;; 4 . .. ;�. � F ,. ,p ;�;;. a� z _ '�;. 237 CHESTNUT ST BP-2004-1081 GIS#: COMMONWEALTH OF 1'VYASSACHUSETTS Map:Block: 17A- 136 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Build'InQ DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2004-1081 Project# JS-2004-1605 Est.Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JDR BUILDERS 074105 Lot Size(sg.ft.): 23478.84 Owner. PELLAND GRACE E Zoning ui�i a litah..: ?Ln nc AT. 237 CHESTNUT ST Applicant Address: Phone: Insurance: P O BOX 66 (413) 665-7587 WHATELYMA01093-0066 ISSUED ON.514104 0.00:00 TO PERFORM THE FOLLOWING WORK.-PARTIAL STRIP, PLY & 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: Q K 6-- 7 O -, THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA N OF ANY OF ITS RULES AND REGULATION Certificate of Occu an Signature. FeeType: Receipt No: Date Paid: Check No: Amount: Building 5/4/04 0:00:00 1700 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo