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17A-267 (2) �I tIAM P� of Nart1jampton z = pp4 9 � �11aSSAC}t 1TSttIS " cN _ �* c� DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street * Municipal Building Northampum, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as iris/her construction sulr: : : sor. The stale defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or t►vo 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 buildiniz 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 B 6 ��assachctsctta � 61h) of 'Narillaillpf till m DEPART?.TENT OP BUILDING INSPECTIONS 212 Main Street ' Municipal Building Northampton, AInss. 01060 1 NN'ORICER'S CO'NI-PENT SA TION INSURANCE ArrmA«T —, (� (li���c/tctnlittdd) xvhh a principal place of businesdresidence at: n►''—t___ /Y�/�' do hemby celmy, muter Tu pi?!i:5 ;iiiC p i]?It1eS of j) rJlll�t (I1:'.i_ ( ) I aJU an employer providing the followiny wore ub compens:lion coven c for my eluployees working on dris jol)� (Lnsurana Corn ny) (relic:Nt1tanbcr) ( ;pir:iien Daze) O I ant a sole proprietor, general cor,lrractor or homeowner (circle one) and gave tired Vic contractors listed i)eiov,' `,to 1mve the Whoving wlorkefs i)ohccies: (Name of ColII^:::]7iToti j Numhhcr) Date) Jame of Convac.or) I is� �.n .° Com.��..y/E o.ic� Nt.m1r �}:�.:.r:uo.'Date) (Name of Contractor) Jnsurincu Compaily/policy NIIII)Nlr) Date) ----------------------- (Name of Contractor) —insu=-z Com'.;::�;y/Policy Nurib-r) (L>:pir.:tio:1 Da C) (r.[iac3t ad!itimil ci�ct if::c.-,-::�:�:t.. .�_..._, ....:aru:i:K: r:c:tain:n�'...eli�•-c:^_�,...•) i O I tun a sole propnetor aid have no one Ivor4ing for ine. afll a ho1lle 0\V?lCi l)CrICr iulI]h all t'hC N0,11:")[case be nwarc thai« iic hn; :r.:r_rs +;r c::p!ry Ir–:c: to c'.:c� :tr�nc�ar.:r_n:di"(I cr not tnccc then tiro units in rcii _3 a oct L`c cc o't cncmrall y cntployc3 ur)�cr the ca:t- :atirn f c,(GL152 nl(S)),r_rpL lien by e homconz)cr for a l]ca:c a lxrmi::r.av-r:_mac C:c Itp,MW of an omployor un" r t1L0 wukot'.CCXI1JKt tioR f tL I undcrawd On a n y of thi,ctittz:;c[:I c,,.y bo 17 c-- niod to ti»IYSxirt:xxzz2 of Indi>_striai offs—of 1;­_x for tin oovrragc VCrif1C11ioo and thet feilurc to:catrc covctagn,ur3 r section 25A of?,(Gl,152 can lead to tlta imposition of :.ir 1 pa aL':ct C'onlisting of a fnx of up to 51.500.00 n:-1Vor in:riris=rrtsctli of up to cn:)-'u n:rj civil perultics in dx form of n Stcp Wcri;Oni_r s^.d s fIm of 5109.00 a dsy t ain_,A ar- - 1'oc dq;utnxstsl ttic u:ly � PC7init NUUIlXS --- .4)t Sigvaturc t>f l i, ..,,cJPc.r;nitt•�- D-t' 1 � 5 _ SE TION SERVICES 8 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone Reg"s ereaome 'mproveme"ntContractorsg Not Applicable ❑ YAdress an Name - Registration Number S Expiirraation Date SECTION 10 -1NORKERS':CO,MPENSATION 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...... ❑ i 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. DeSnition 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 I I I SECTI30NI5 DESORIP OwOF PR'OOP�OSED�WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing {ice Or Doors ❑ Accessory Bldg. ❑ Demolition❑ K1.w Si ns ['] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: n f O Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 6- If New ouse aWd.o i,-dd i' tion=ao existingffiousing =complete t}ie followin : 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? ''"f `-�' 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. 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____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 AGGENT'OR�CONTRACTOR APPLIES FOR BUILDING PERMIT' 1 [ as Owner of the subject property hereby authorize i �' �ril/�i1 _to act on my behalf, in all matters relative�,t fi work authorized by this buildin permit application. .r . , 3V- 3/-0 3 Signature of Owner Date l 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 penalties of perjury. 6rcpj"� rv� Print N e Signat 0 Agent Date Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document # B. Does the site contain a brook, body of water or wetlands? NO DON'T 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: __ S !Y City of Northampton SSMI tus of Building Department Qdrb Cut✓.,D we ;w Its ,1 Main Street 7430'�erlSeptr 2 Room 100 V ate lWell v Northampton, MA 01060 TwoSets-af � 2g(J� MAR or 13.687-1240 Fax 413-587-1272 Plot/SIte;Plans APFLjCATION'r0 CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION 1.1 Pro ert Address: This section to be completed by office P Y h^L� 1-[ Map Lot .Uni Zone Overlay District _ l� Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: © A id- !S Name(Print) Current Mailing Address: q Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3 - ESTIMATE CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only ` com leted by ermit applicant 1. Building ©� 0 (a) Building Permit Fee 2 Ele :.rica! (b) -timated 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 Q � This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date BP-2003-0826 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2003-0826 Project# IS-2003-1351 Est.Cost: $5000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: HOGAN REMODELING 136954 Lot Size(sq. ft.): 15594.48 Owner: HALE TED OLIVER& Zoning.URB Applicant: HOGAN REMODELING AT. 96 OAK ST Applicant Address: Phone: Insurance: P 0 BOX 745 (413) 532-0756 Workers Compensation HOLYOKEMA01040 ISSUED ON:413103 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 Shmature: _ FeeTyDe• Receipt No: Date Paid: Check No: Amount: Building 4/3/03 0:00:00 1035 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 96 OAK ST BP-2003-0826 GiS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17A-267 CITY OF NORTHAMPTON Lot:-001 Permit: BuiidinQ Categor: BUILDING PERMIT Permit# BP-2003-0826 Protect# JS-2003-1351 Est.Cost: $5000.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor. License: Use Group: HOGAN REMODELING 136954 Lot Size(sg. ft.): 15594.48 Owner: HALE TED OLIVER& Zoning.URB Applicant: HOGAN REMODELING AT.- 96 OAK 5 Applicant Address: Phone. Insurance: P O BOX 745 (413) 532-0756 Workers Compensation HOLYOKEMA01040 ISSUED ON.4/3/03 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: L14 i#A 3. THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATION _ Certificate of Occu an Si nature: FeeType: Receipt No: Date Paid: Check No: Amount: Building 4/3/03 0:00:00 1035 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo