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17A-224 (4) O O Lzty of X azt4aillptall I-1 DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 ,M e ,r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to act as Lis/her construction supe: .'Sor. The 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 occupancv until the work can be inspected. If the homeowner hires other trades to perform work (electrical, plumbing & gas) the homeowner wiII 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 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_ 1 Z I , Z I D (.--,- Address of work location �01 O� O (rIti) of �v�Ctl fl}cillliJfD11 - �— DEPARTMEN'T OP BUILDF)\'C INSPECTIONS 212 MCLin Strcet ' Nfunicipal Building Northampton, Mass. 01060 «lorsn:R'S CO'N[PENSATION CgSURA-NCr AF=1 {VIT r -- (�.i�r�sxJpernl lice) wnth a principal place of businesslresidenc_ at: (sffr°tJc�tJ/ chip) do hereby ccrify, under the pr-Lns and penalties of perjury, h:1 ( ) I am an employer providing die following v,,orkcr's comncnsZ:jon cove Zgc Ior im, elnptovices Nvor�Dng on Cilis job'. (Lase== Com=a ,) (PC6C': NLm bcr) --- (—t_-,-Pi_IT3 On Due) ( ) I am a sole propretor, general contractor or homeowner (circ:e one) 2-ad have hired the coouactors Lsted below v-rho have the followi3 9 , c':cef`s co oensanon pclicies: (tN�smc ui Co_::avrl (InRranc Cornoi�}/Pcic; ' umccj (_ti)ir�:_0 I��tc) (Name of Contra(7ior) (Insu znc Comoam;Poli -' Daie) (name of Connacto:) (I>ZSUrdocn Company/Pou-q. Namb�j) (Expirdoo Date) (T:aJm of Comractor) (Ir =c-- ComDaD /Pouf• ttxp won Da c) . (-Hach ooJ e�.d ^r to oa U_=m_c.on) - (P�I am a sole proprietor and have no one wor�' g for me. home owner pe_rfonuing all the work myself. NOT pl=s be cwzrt tfi,,'t Ja ho'co",'t,ccxyloy pczooJ to do -.:.c�ro c rr,zir work an of o.ot¢port t!`C L.`-r-z=atj in Wazo±the bor, o I-do a m the pond, CI-BY w be ctploy J u c the o-- cc Ac (GL15)—I(5)�`ppLcatuon by n bo%.o o=fc_6 -�or PC-rah ray-_`3— c Icg-.J nzau of en Mayor under duo W, oe,Coon,--ti Act_ [undcr.�.a,d of tbij aat�a..y bo fos.ani.a.d to tbo pcp�.rtmmt of l id/.cvdcal..-f O1Too of oa+for Lb' oova�^La L clloo�� L l at o saauc-covczr�c undc za�on 15 A of MG1_151 nn 1-!A Lo cbc Lmrxiz.of a m nJl p—Wi oo r,�of a riac oC S 1500.00 or o up to coc Y--r pma-ltia in dk form or,Stop Work Ord--end o f�oC S 1 Q0.00 y a�aia4� _ Fa d4'nr.'�1 u.c Daly --------- / LCrID71 �'tllIITt�C7 .--- 9nacuzn of Li CrITUUCC e SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: l'-eakil t'Ll License Number r Address Expiration Date Sin re Telephone 9.Registered Home Improvement Contractor , Not Applicable ❑ Company Name Registration Number /J",- 61 / /Y L isle' Zip+ r9�G`fiyl��'J r A dress /� Expiration Date /Y I) C �C>y1�l W i 6!f, _Telephone 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....... No...... ❑ 11. ..Home Owner Exemption 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-vear 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 D Accessory Bldg. ❑ Demolition ❑ New Signs [ED] Decks [E:J Siding[0] Other Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes U1 No Attached Narrative Renovating unfinished basement Yes X No Plans Attached Roll Sheet sa. If:New?hotrse°a'nd oradrlitionyto ez'stinq housinclr,comli ek the follow rig; 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? irepiaces 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 7a=OWNER AUTHORIZATION --TO'BE COMPLETED WHEN OWNERS AGENT OR'CONTRACTOR;APPLIES FOR BUILDING PERMIT 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. i Signature of Owner Date --� i ��s `' ^'T y�l��t.P<?v C'� \�C t\t��U,\ j�.�c,�( l tv a caner/ uthorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the besof my knowledge and belief. Sign under the pains and penalties of perjury. Pri Signature of Owner/Agent 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 Setbacks Front Rear Building Height Bldg. Square Footage 0 Open Space Footage (Lot area minus b1dg&paved #of Parking Spaces (volume&Location) A. Has a Special Perm it/Varunce/Fimdi ng ever been issued for/on the site? NO \ ] DON'T KNOW [ ) YES 0 IF YES, date issued:, | IF YES: Was the permit recorded at the Registry ofDeeds? NO ( ) DON'T -- IF YES: enter Book Page| � and/or Document#r-------- --! B. Does the site contain abrook, bodyufwaternrvvet/ands? N8 /—� DON'T KNOW �-� YES IF YES, has permit been ur need tobeobtained from the Conservation Commission? Needs tobeobtained \~�/~� Obtained y�\ Date\~� ' C. Do any signs exist on the property? YES /—� NO IF YES, describe type ' ' ' ' D. Are there any proposed changes to or additions of signs intended for the property? YES /—\ NO IF YES, describe size, type and location: �--'-----� E Will the construction activity disturb(clearing, gradingexcavation,or filling)over 1 acre orioit part ofa common plan that will disturb over 1acre? YES �� NO {D IF YES, then a Northampton Storm Water Management Permit from the DPW is required. ` h Department use only City of Northampton status of Permit Building Department Curb CttlDnveway Permit 212 Main Street SewerlSepttc Availability r Room 100 WaterlW6 1 fAAV ai t;ti iii , Northampton, MA 01060 Two Sets of Structural Plans phone 413-587-1240 Fax 413-587-1272 Plot/Site Plans- Othef Specify APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING S CTION 1 -SITE INFORMATION Of 1.1 Property Address: This section to'be completed by office Ma Lot Unit. C -� Zone Overlay District Elm st Districfi r CB District SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: IC me(Print) Current Mailing AI�ddrerssg duce Z �i L-tl , CJOq — Z Telephone S�gnature 2.2 Authorized Agent: Name(Print) Current Mailing Address: 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 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 Section For Official Use Only Building Permit Number.' Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 198 NORTH MAPLE ST BP-2007-0650 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-224 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A) Category: woodstove BUILDING PERMIT Permit# BP-2007-0650 Proiect# JS-2007-000948 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.ft.): 6316.20 Owner: MCKEEVER JAMES P Zoning.URB Applicant: MCKEEVER JAMES P AT: 198 NORTH MAPLE ST Applicant Address: Phone -insurance; 198 NORTH MAPLE ST (413) 584-2250 FLORENCEMA01062 ISSUED ON:1211512006 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL PELLET STOVE 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: s iuxi. ©A- OG THIS PERMIT MAY BE REVOKED BY TH ITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGUL ION Certificate of Occupancv Signature: FeeType: Date Paid: Amount: Building 12/15/2006 0:00:00 $25.00246 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo