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17C-145 (3) Oq"'C�M�'TO Glify of Nort4anipfan )T-) � � �iassac3�asrtfs DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR '212 Main Street • Municipal Building '>a 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 his/her construction sups:,- 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 fami -__ 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 fegulations. 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, �Gj �, „- V�� 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. Daze Address of work location I ^r i �0 •-r �Oy F E (riff Pf �,Torf11alli 10 I'll - __- A y f 91 c3 akchnscIIa' j © DEPARTMENrT OP BUILD0\10 INSPPCTJOIIIS - j 212 Main Strcet Municipal Building Northampton, Mass. 01060 a WOIUCC IS CON/Q'ENSA77O.N L'A'SURA_NCE AFF M�,Arj-j- (liccusxJpermitfCC) ,IrlLh a principal place of businessfresidence at: -- ----- (phone') (sut/ci ty/statdzb P) do hereby cerdf;, under the.pains and penalties of penury:, =.hzt 1 - { ( ) I am an employer providing the following worker's comocasabo; coverts for uty etnploveeS Worlong on tlus job: i (Laniran= Comr,7-m') (PcLic: :piration Due) i i O I am a sole proprietor, general contractor or homeow-ner (c c;e OP_e) and have hired the coon-actors listed below vqbo 11zve the following workef s coLptasa lon pokiest i (i+3SI]C 0� C0�`.^Ci0") (In;tranc:; Comoany/?obc; NU.Mh-_:) (Ex:)1,dt3on 1111C) (Na me of CoanT 0r) (LrLSUI_UCC Como_an-vipolic Number) ( xD6 ..lion Date) (Name of Connaclo.-) (tract.Comrtan)•/Policy Nusbu) (Expiration Datc) I (Name of Contractor) (Losuraac-c Company/Policy NUM)%.r) (Expiration Daic). (aQSGb ddi i nets!Ica.f ncaa«•w mc?uc� arorm,�oc pertaiains do.y O I am a sole pr-opnetor and have no one working for me. —__�m.-a home owner performing all the work myself. i NOTE:G.p1C3G K LW]SC ti3:N' C hoMCOµ'OCT]l 1y0 COMPI_/ P�__I-O=IG d3 nCpau Work oa a d,,T.n'-z of noe niece tern t 70 art in-4-6 the bomootwcr r..6.or oa the Qouad,LFpurtross tbeeu c r oo(C-_-z-_tty 00=.d_,d to be eit)loy=uncle the�v-k&:, *'oo A,=(GUI 52-=1(5)).=pptin.00n by a bo=o%-=fcr a licz:or pamh r=T midax the Icvj nave of nn== loyx under tlto woricela cooapo�Ao- i I I u-d=vL.nd dIA a copy ortbi, my e,f----i.d t.t>.n�pa oT,—orb .r.ma roe Lb. cova-aSc vQirevioo,ud the L-itLm to soauc bovcrx&e t=dc souioa 23A of),(GL 151 c=ied to the maim of a-imim-J pca 16; oomisiag of a fine orup to s1300.00 dfor orup to ooc yam.,e.nd cj a pca.tia is 6,room or.Stop Work Ordcs and a fl=of 5100.00 a day apd=me - i For dep-msel u,e only - Permit Number Lot Sif,- atumofLicQ>_sc crmiucc e l SECTION 8-CONSTRUCTION SERVICES t 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone errr Not Applicable ❑ Company Name Registration Num er Address Expiration Date 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...... ❑ The current exemption for"homeowners"was extended to include Owner-occupied Dwel inQs 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 be/she shall be responsible for all sucb work performed under the buildine 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 re onsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoning and State of Massachusetts General Laws Annotated. Homeowner Signature r SECTION 5 DESCRIPTION OF PROPOSED WORK(check all rapplicable) New House ❑ Addition Replacemen s Alterations) Roofing Or Doors --2_\ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Sidin ] Other[d] d C a e/1 C.r. vAC�w; — nr� Brief Description of Proposed �� AC '"� ° Gv Work A .� � 1 C�-hc�,"{� o f C ca't�1 , .i ,o 6J,v►4��'� S"/%-, '(4 Alteration of existing bedroom Yes No Adding new bedroom Yes No -A Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet —^r--��F �+.,. ,�, �` �•;*�s.�?- ��„_ ,ms;.µ, m.�.. i.^"�.Ea�.;�.r.- ..� - ; sa=1f�`l�e��o us��anc ' iti0:��cextstic�cr�tn�t�"s�na �ornptete:t o tuyt�inct: 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-OWNERAUTHORIZATION TOBE.COMPLETED WHEN OWNERS AGENT ORCONTRACTOR-APPLIES.FOR'BUILDfNC PERMIT 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 :;�4 c-� ,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. 44- .l AS (\J O .j A�4 Print Name �-- Signature of Owne dent 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 Setbacks Front — i Side LF R:' L:' R:` Rear � 17—i Building Height ' - L_- Bldg.Square Footage % r— Open Space Footage % 3 (Lot area minus bldg&paved parking), #of Parking Spaces Fill: volume,&Location)i 3 A. Has a Special Perm it/Variance/Findin r been issued for/on the site? NO 0 DON'T KNOW YES IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DON'T KNOW 0 YES IF YES: enter Book Page'; and/or Document# B. Does the site contain a brook, body of water or wetlands? N0,1<,-1 DONT KNOW 0 YES 0 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 0 NO, � IF YES, describe size, type and location: } E. Will the construction activity disturb(clearing,grading,excav or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 , NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. j, !! City ofl Nortf�ampton �f ' Building Department li 7 u05212'Wir Street Room`100 « NorthaMpton-MA 01060 phone 413-58T--1240 Fax 413-587-1272 r APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING `SECTION 1 -.SITE"INFORMATION " Th�srsectron to be completed by ace 1.1 Property Address: Kelef �� 'Zone.' � �=Oveclay"'Distnct�..w ��Elie°5t�istrtct �r �.�CB.p�stnct SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT- 2.1 " 2.1 Owner of Record: A G S�e Rwo.d JAS 't /t z W /V J JA V 1 0 Name(Print) Current Mailing Address: ^� Telephone ,7 � Signature � 1 '7�,0 s Z" 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 ter° .y�'- w ' a .Buildin 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=0 +2+31-+4+5) 'Check Number, Z2W "- This Zectiod For Offcial.Use Only ..Date" Building Permit Number' Issued: Signature: • i Building Commissioner/inspector of Buildings Date 28 KEYES ST BP-2005-1208 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C- 145 CITY OF NORTHAMPTON Lot: -001 Permit: Buildina Category: BUILDING PERMIT Permit# BP-2005-1208 Project# JS-2005-1627 Est. Cost: $10000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sg. ft.): 11238.48 Owner: NOVACK THOMAS&ALISON Zoning: URB Applicant: NOVACK THOMAS & ALISON AT. 28 KEYES ST Applicant Address: Phone: Insurance: 67 SHERWOOD RD (201) 768-5292 O NORWOODN307648 ISSUED ON.619105 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE OLDER WINDOWS & DAMAGED SIDING 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 Signature: FeeType• Date Paid: Amount: Building 6/9/05 0:00:00 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo