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42-165 (3) O¢•S tSAaf p�O �853ACj(IISCtfD r � DEPARTMENT OF BUILDIN G INSPECTIONS INSPECTOR '212 Main Street • Municipal Building Nordi,unpton,MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as has/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 fame 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 r',egulations. 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 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 y 'e;+s1itchnscII's u Q DEP:IATME1,T OF 13UILDf?-,1C INSPECTIONS 212 Main Strect Municipal Building Northampton, Mass. 01060 WOR CER'S C014P ✓NSA'aON MSURA-NCE AITMAVI-1- / (ltccns�-Jperm�tfcc) %1pith a principa-1 place of businessfresidence. at: — -- - 6160' hone-i!) ( city/sta.td�p) do hereby certify, under dic.p altie ofp^ :hai r ( ) I am an employer providing fire r�lowine''%vorl:ces corrloc:�y�o, cove--Sc for Iny employees wor�Dng on this job: (L nLman=CoEizzay) (Pelic:N.U--Zb--T) -- (r, it Lion Dam) O I am a sole propnetor, general contractor or homeovwner (c c;e one) amd Lave hired the conaactgrs listed below who have the fo(jo in2 worker's camoen_saaon policies: (Nar,)C Of Coa—1 nc�or) (In_<uranc Cotnoan)-iii olio;?�t11II1�G:) (Y:atFJ�O 1�11C) - (1 lame of Contractor) (lrj-s-a ncc Compan`vPoUc: Number) "tu Lion Date) (N.me 01Coaamcla;) (Insuraac; (Expiraoo Daic) (Name of Conamctor) (Lasurdnc-- Comcz..aylPoUcy Numl s) (ixpi-,ioo D=)_ (etxach:daiCCC=j CSC<,'j nCCG _V to jr,e.14C iaforna,aoo pcztaiaias w.11 ma7-_cn:s) O I am a sole proprietor and have no one worL-jng for me. ( ) I am.a home owner performing all the work myself. NOTE:plc=be cwllt tfi,•_L-jo 6cmm.+�cra wtio cnplay pc:oai to dD repair work oa a d%,�1-Z of tux tnas the.a tr=ue turfs is u3i�the bomoowncr rc�da a ca the p-oun�,zppurtca:r:tbcee c-c nue�-�e-.11y oecscd..-cd to be 'Play'untie the�.ui rt r=x--.ica A=(G052-=1(5)1,:.pplic 6=b-y a bamcoax fm c tics_or p=mit=y c%idco=the ICV1 nntw ores crgtoyx uadar dao Wock4e-Compam.tion AcL I uadcn.+.nd the a Dopy of llua mtcmcm m.y ba fo.a nrdad to ty�p ��of Inc4.�ri.1 ncad..&O(G—or ttiur.non(oc tb- cova'�c vn'ifietioa end lh1 L-iliac to scrurc kovcy�untie seetioa 23 A of MOL 13,1 na Ied to the i-Mpo ioa of eimia P=-% io eo—ma of a fine of up to S I}00.00 rt&Oc nzp-iyo=.�o(up b Doc ye r ead aril patio in dc form of a Slop Work Orde aad+ rim of S 100.00 d:y cpi,:a tae For d�p—...�,t u,e on7y Pcrmit Numhcs Y t gxm of Lican5cc/Pcrrn ucc —D3� J SECTION 8-CONSTRUCTION SERVICES .f 1 81 Licensed Construction Supervisor: c Not Applicable ❑ Name of License Holder: ���` V` " �( 071 t License Number LlAddress Expiration 4113 66 sv1_3 gnature Telephon 9.:ITe isteired lriem"cveiiienCoritra'or Not Applicable ❑ Company Nam Registration Num er Address Expir ion Dat Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L.c.-1152,11'25C(0)) 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...... ❑ ire , , 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-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 SECTION 5--DESCRIPTION OF PROPOSED WORK(check all applicable) New House Addition ❑:,. Replacement Windows Alteration(s) ❑ Roofing Or Doors r1 Accessory Bldg. ❑ Demolition New Signs [0] Decks [[] Siding[0] Other[[:3] )Efief Descri ption of ropo ed r, r Work: rvu a n w r LL 6,, r't 7n-2�i Alteration of existing bedroom Yes No Adding new bedroom Yes �o . Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -She sa.Ifyl+teW rouse ah& a c itto mexts iii 1 OUSIfid.<<camptefe the 61I6 ing a. Use of building:One Family Two Family _Other K.Q b. Number of rooms in each family unit:2 3 04'rn'`Number of Bathrooms c. Is there a garage attached? AO d. Proposed Square footage of new construction. v�L L� Dimensions 32- � ` f e. Number of stories? wp f. Method of heating? Fireplaces or Woodstoves V'-0 Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction wo© i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain - Yes No r 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_X_ City Sewer Private well City water Supply SECTION Ta-'OWNER AUTHORIZATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR`'APPLIES F611 BUILDING PERMIT as Owner of the subject property hereby authorize &Z rZI, ES� to act on in 11 matters relative to work authorized by this building permit application. Si natu of Nner Date I, 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 un r the pains and penalties of perjury. rzt sS � t Name �tur' wner/Age nt Date Section 4. ZONING All Informatibil 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 — ' I ' F /Z6 Setbacks Front T Side Ls R:= L: R:L lLA) � Rear 7 Building Height Bldg.Square Footage % '! 3 1 Open Space Footage % 12 (Lot area minus bldg&paved parking) #of Parking Spaces ,7 Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for ion the site? NO Q DONT KNOW 0 YES i IF YES, date issued:1 a � IF YES: Was the permit recorded at the Registry of Deeds? L-) PIze vt(:I L.T 0,11"` NO 0 DONT KNOW 0 YES C1:r,( 0e NOV-D-+A'.A-P,�-C-NA IF YES: enter Book + Page' and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0 IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Q Obtained 0 Date Issued: C. Do any signs exist on the property? YES Q NO IF YES, describe size, type and location: i D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 - NO 0 IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ompton apartment . tveayP 21"'1 n Street " ' 2 ^0(� �I�n 100 1 a r e ua a to L �� � North mpt n; MA 01060 Tuuo e s o Sttvr. ral�Pans k�� *� i 13 /-12 0'Fax 413-587-1272 PtottSlt an � �t Othec Spee�fy ..F Pr,� .. APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1.-SITE INFORMATION This sectron o be campCeted byaffice 1.1 Property Address: _ (q f c? � vVl ✓l Ac C1. UI Map Lot Unft Overla�r:'D�strrcf vi ;- •E].M St D!S-pc -;CB Oistiict SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: ?10 A e V c� flf? A, po Y o& 4o 6,q �—, Flo.-e-I Ce_', 4o(04 Pr Name( C g Current Mailing Addr s j � �� _S � •� d J Telephone L Sign ture 2.2 Authorized A ant: s N (Prin Current Maili ddress: Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item - Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building -5-0 Uod (a)Building Permit Fee 2. Electrical (b)Estimated Total Cost of -7 0 Construction from 6 3. Plumbing 8 o G Building Permit Fee 4. Mechanical(HVAC) / 5. Fire Protection 6. Total=(1 +2+3+4+5) —7 Check Number This Section For Official'Use Only Date- Building Permit Number.' Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2005-0359 APPLICANT/CONTACT PERSON Pioneer Valley Habitat for Humanity ADDRESS/PHONE P O BOX 60642 FLORENCE (413)586-5430 Q PROPERTY LOCATION BLDG#2-840 WESTHAMPTON RD MAP 42 PARCEL 165 001 ZONE SR THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid "- T_yneof Construction: FOUNDATION ONLY(SINGLE FAMILY W/ACCESSORY) New Construction Non Structural interior renovations Addition to Existing Accesso_ry Structure Building Plans Included: Owner/Statement or License 071711 3 sets of Plans/Plot Plan M LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON ATION PRESENTED: oved Additional permits required(see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND/OR Special Permit With Site Plan Major Project: Site Plan AND/OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received&Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Co sion Signature of Building Official Date Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health,Conservation Commission,Department of public works and other applicable permit granting authorities. *Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of Planning&Development for more information. - x BLDG#2-:80 WESTHAAeTON RD BP-2005-0359 GIS#: COMMONWEALTH OF MASSACHUSETTS lDj%k:42 165 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A) Category: BUILDING PERMIT Permit# BP-2005-0359 Proiect# JS-2005-0478 Est. Cost: $75000.00 Fee: $157.50 PERMISSION IS HEREBY GRANTED TO: Const.Class: 5B Contractor: License: Use Group: R4 SARAH STULL 071711 Lot Size(sg.ft.): Owner: Pioneer Valley Habitat for Humanity Zoning: SR Applicant: Pioneer Valley Habitat for Humanity AT: BLDG #2 - 840 WESTHAMPTON RD Applicant Address: Phone: Insurance: " �P0 BOX 60642 (413) 586-5430 (� NCEMA01062 ISSUED ON.]018104 0:00:00 T RM THE FOLLOWING WORK.-FOUNDATION ONLY (SINGLE FAMILY W/ACCE POST THIS CARDS FROM THE STREET Inspector of Plumbing Inspect4` D.P.W. Building Inspector Underground: Service: Rough: Rough: House"#* Foundation: Driveway Finale Final: Final: Rou 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: Receipt No: Date Paid: Check No: Amount: Building 10/8/04 0:00:00 3346 $157.50 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo BP-2005-0359 BLDG#2-840 WESTHAMPTON RD GIs#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Map:Block:42- 165 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Lot:.Blo Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) BUILDING PERMIT Category: Permit# BP-2005-0359 Project# IS-2005-0478 Est.Cost: $75000.00 Fee: 1$ t:$7 PERMISSION IS HEREBY GRANTED TO: Contractor: License: Const.Class: SB 071711 Use Group: R4 SARAH STULL_ Lot Groula.R4 Owner Pioneer Valley Habitat for Humanity eV Habitat for Human Zoning: SR giant Pioneer Vallity AT. BLDG #2 - 840 WESTHAMPTON RD Insurance: Phone: Applicant Address: 1413) one.* 30 P O BOX 60642 FLORENCEMA01062 ISSUED 0 101810 0:00:00 TO PERFORM THE FOLLOWING WORK FOUNDATION ONLY (SINGLE FAMILY : W/ACCESSORY) POST THIS CARD SO IT IS VISIBLE FROM THE STREET Building Inspector Inspector of Plumbing Inspector of Wiring D.P.W. Service: Meter: _ Underground: Footings: ,�f9a ) /l�/(� Qk' /Q-a✓� -�y House# Foundation: Rough: Rough: `� ©k 1!"c? •O� Driveway Final- Final: Final: Rough Frame: Fireplace/Chimney: Gas: Fire Department Insulation: Rough: Oil: Final: Final: Smoke: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULAXONS. , Signature• '-- Certificate of Occu anc Date Paid• Check No: Amount: FeejyRE Receipt No: ------ 10/8/04 0.00:00 3346 $157.50 Building 212 Main Street,Phone(413)557-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo