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06-010 (2) �Tt1AMp�, . O O Cr if of Xar#4a11tptan a tea- -::- J. 3aa. DEPARTMENT OF BUILDING INSPEC'T'IONS 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 1-as/her construction sup(:: . 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 hales (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 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 4� ( TNI of �ctz fl)a�il}itoil - � -' E - rl as anrh[tsrlle' v DEPARTMENT OF 13UIL-Df)\C INSPECTION'S _ 212 Train Strcet Municipal Building N'Orthampton, Mass. OIOGO «`ORIQ IZ'S COMTENSATION -GNSUTAhCE :tITIJ)AVIT (1;ctvs..xJperm�tics) «pith a pru'-Icipal place of busineSS/residence al: (hlionc') (sl rat/c�ty/scatcln P) do hereby cerdi -, under dic.pplm and pen21ties of perjury., thal ( ) I am an employer providing flit following rvorkcr s cocnnensn ior. cove-^fie for Illy etnplovees working on this job: (Lnsst7--nc-- Coca=-v) CPCLIC! NIL-Liyu) (T':-piraaon Daz`) ( ) I am a sole proprietor, general conu-ac-Lor or homeowner (c cie one) and Lzve hired the cone actors listed below «bo hzve the `olloWIDS worker's G7��erL�aon policies: (Name o;Co.^=c—'orl (Ins rand COST1Oar1}"hGIJCi �1UQ1=CI) �.`-71fJ�^ Date) - (Name of Concaezor) (It>ssrznc Comma}"rPolie; Nuncrr) (Eko r iion Due) (Name of COUMC'IOr) (I-m�cr- Company/pol,•q• N"mb.r) (Expir dco Datc) (Name of Coanctor) (Insura.acc- Comczay/PoLcy Numb-r) (Expirddoa Date) . (assu3 d�i�oa!GXG.fncc�sary mcu�inform.Z'oa pcta to.JJ ocasto s) O I am'a sole proprietor and have no one working for me. Va) I am,a home owner performing all Lbe work myself. / NOTE:plcsc be ew:ut Lb,:w-L-Jc -bo ca pla),pczoui w d, -.• ,b cr rrrair-ark on,d,•c11_Z of aoe mocc th m ' -> ,,in%ti ch cbc bomoowmrs ra dca oc cc LSc 7- uo,:S,�p�r cnls tbeen cox G-s..:-ty ocerC_-2,i o be cnploycs snc c the ,aicz ct--=p—*_gym Aa(GLIS2 -I(S)O 4p UCZ-iaa b-f a bomooa-=fcr:lice or paznit zy ctiidcocc cbc 1cga1 rt+ of an eoP)oyx under dw Wor4 ,Compomizroa Au I uadcsuad db d a oo"of tbi.cza-�W—y bo foe xercl.d to tiA A-te OTI-of 61-• -for the coves &- vQ-il'c%tioa and t!u C-A=c to&=Am tovtrabz under scczioa 2 S A cf hidL 152«n Icd to tba i=pnziiioa of 'm' ,t PCIIal 8 of a S=or up to S I-GM,00 aridror oC up to ooc yr,Lod c,l pea+-hies in t5e form o(a Sjop Worse Order and a fish of S I WOO s d-- 'Pins me / For dq.rtm=�u.c only `- /v/S/ pG7m,11 Ht1IDt�7 P^ sat SiPnaLUn of Liccnscc/Pc cc L e J P r � SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9r Rbgrster6d-14o`me lr ldroverirent.Contracto--_..s. Not Applicable ❑ ..'e�.c.::Etuw,r.tsmx....s..fi.+ Company Name Registration Number Address Expiration Date Telephone SECTION 10=WORKERS'COMPENSATION INSURANCE.AFFIDAVLT(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...... ❑ wi 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-owwn-a.par_cel.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. omeowner Signature SECTION 5--DESCRIPTION OF PROPOSED WORK(check_allappiicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[O] Other[o] ief Description of Prgposed _J • Work:— LGl. �d' dyN Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa_[f[Jev�rrocrsev: rtd oraddltl'onfaexstnc . oustc�g�corptettzfFL`ovrig: 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 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-,AU—T,",QRIZATI©N TO BE COMPLETED WHEN OWNERS.AGENTOR:CONTRACTOR:APPLIES FOR,BUILDINGPERMIT- 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 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. Print Name S Signature of Owner/Agent U 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 Frontage Setbacks Front Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Locat on) A. Has a Special Permit/Varance/Fimdi ever been issued for/on the site? �� �� NO \_��� DON'T VV �~/KNOW YES �~� IF YES, date issued:' IF YES: Was the permit recorded et the Registry ofDeeds? NO [ ) DON'T YES ~~° IF YES: * enter Book Page! / and/or Documont#( | �� �� B. Does the site contain a brook, body ofvxuterorwetlands? NO \_��� D0NTKNOVV �_/ YES �~� IF YES, has a permit been or need tobo obtained from the Conservation Commission? Needs tobeobtained �~� Obtainad �~� Date �~� \~� ' � C. Do any signs exist on the proparty �� ��� YES �~� NO v�� 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,gradingexcavation,orfiUing)over 1 acre oris it part ofa common plan that will disturb over 1acre? YES [ > NO [ } �� �� |F YES,then a Northampton Storm Water Management Permit from the DPW iorequired. City of Northampton Permtt� RUildinn nPnartmPnt t^�,'iZ kt ]n�c� --�_ - K � 212 Main Street ee ept Room 100 Ul ater' Fa L" AyatJaf7ilit ? _ ivy Northampton, MA 01060vvices otretctrayEat7s i ' Q i phone 413-587-1240 Fax 413-587-1272 RIatSitPla s x APPLICATION-TOrICONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION-1--SITE,INFORMATION: This section to he.completd by office 1.1 Property Address: .�/I p��_ � ,pp ' (�AM vV & kei Mats Lot Unit Zone? Overl=ay Distract -EM ' t Distract .. _- ',C Disfrr�t. SECTION,2,-PROPERTY OWNERSHiPfAU T HORIZED ACENT- 2.1 Owner of Record: 14&- i.ErJ E - SVMonis Name(Print) Current Mailint Address: _ O q 13 gam� 6. S Telephone ' Signature L41 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 sl OD (a)Building Permit Fee 2. Electrical qq (b}Estimated Total Cost of owl 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 Date Building,Permit Number.. Issued: Signature: Building Commissioner/Inspector of Buildings Date 595 HAYDENVILLE RD BP-2007-0392 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 06-010 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category:Non structural interior renovations BUILDING PERMIT Permit# BP-2007-0392 Project# JS-2006-002033 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 548856.00 Owner: SYMONS HELEN E zonin SR A Ucant: SYMONS HELEN E AT. 595 HAYI)EN iLLE RD Applicant Address: Phone: Insurance: 9 HIGH ST (413)268-8322 HAYDENVILLEMA01039 ISSUED ON.101612006 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL FIREPLACE INSERT 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: Olt' fQ-//• Q G THIS PERMIT MAY BE REVOKED BY THE ,ITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULA IONS. Certificate • f Occupancy Si nature: FeeType: Date Paid: Amount: Building 10/6/2006 0:00:00 $25.00147 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo