42-165 (4) � r0 tiTp e —
3 vzi�. �rf,-CaT' Ilani�fnn
�M—ncif e•r rlSy
. L
DEPARTMENT OF BUILD;)-�C INSPErto,aS .
I 1 - _
P -- _ �r 1 ��'21: m SLr�ti Afunici nl Bu,ld nr,
l::5 1 �7Q2 1� P �.
I�Orf_flz?;PL"On' AS f4_s. O]OGO U •-�_-
r Square Footage
I
--' A 1IMpun t
i 5 7�
1st Floor @ $
2nd Floor E $_30 `y S-D Z i ms's
i/2 Floors, Attic. Garaae
Dec:, Porches
TOT=
`t
ENERGY CONS ZION APPLICATION FORM
FC�R�LO�T=�2ISE�MIDENTIAL NEW CONSTRUCTION
1 �
/ )� CC
.J�.t e7e?. ��t�lPy� 1'�Q�ai 7r! 7 �.1
Ply
Applicant Name: _ ✓ 14 m a�'1 Site Address- �C-S NNW—
Applicant Address: T 1• b". 4 el S - City/Town: v lj 4 o
c Use Group: —
Date of Application: p_
Applicant Phone: X86 — S`/ O Applicant Signature_
Compliance Path(check one): '
Prescriptive Paclfage(for I-or 2-family residential buildings not heated by electric resistan¢c)
Fill in all values that apply from Table J5I l b: Package Number(A through KK): .� f
a. Gross Wall Area sq,fi f. Wall R-value R-__��
b. Glazing R.O.Area 8 sq.ft. g. Floor R-value R- Q
a Glazing%(b+a) h. Basement will R VA
d. Glazing U-value ®3e i. Slab Perimeter - N�
e. Ceiling R value j. Heating AFUE l -3 70
❑ Component Performance(Minuid Vide-Oil)
Climate Zone(from Figure J622) [) Zone 12 0 Zone 13 0 Zone 14
Attach Trade-Off Worksheet from Appendix J,(and HVAC Trade-Off Worksheet, if applicable)
13 MAScheck Software
"ith Compliance Report and Inspection Checklist printouts.
, +
(] Systems Analysis 0 Renewable Energy Sources
Attach approved Analysis
Official's Name: AvAOW Lx .2 _ Official's Signature:
Application Approved [ Date of Approval: oo$�
Application Denied El Date of Denial:
Reason(s)for Denial: a a
(over for more) BBRS I1/ 07
$ � �Ti(asaa�3�usrtts -
r
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Muuicipal Building
Northampton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sup,,. .• ;or. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fdnu-ffy-_
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 eegulations. 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, 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
� r
I i ,
_0 Oy
F E CriiL of 'Nort 1JR11113 toil - - -_
��cyak(ti nsc(ta' —
w`c� DEPnftTkiENU OP BUILDr)\C INSPECTION'S ;
212 Main StrccL • 'Kunicipal Building
?-rorthampton, Mass. 010GO
I �
WO'R CER'S CONITENSATIO.N GNSURAINCE Ar,=AVIT'
I
1Iy l
(Ii ccUScr-Jperm)ttcc)
,Vith a principal place of businessfresidence at: -- -
aa
,� 'S
(su-t~t/a rr/natcra p)
do hereby certify, under thc.p?-'M and penalties of perjury, :hat
( ) I am an employer providing the following iworkcr's colnocrisZDon cove age for im
etnplovecs worUng on this job:
{ (lanir-_n=Company) (Poticr NU-mixr) -- (r=:-pirz or, Dzl`)
I
( ) I am a sole proprietor, general contractor or hotneow'ner (c cie one) and have hired
the contractors listed below wbo hive the followi p- workers cooJen_SaIIon pokles:
('Na Ic O- Con'nc-,O-) (Insur3nt CoinpanyPiobCf ?�tlIll t:) �_:)IrJ Q? 1111c)
i
(Name of Coaommor) (instrraoec- ComoanvrPoUm, Numccr) (-EiPir.:tion Date)
I - -
i
(Name of Coainci ) (lnsuraae: Compao)•/Pouq' N;lmbcr) (E--,:piM6on Date)
i
I
(Name of Contractor) (Iosuran= Compary/Policy Number) (Espirz6oa Date).
(nIIa.Cb ::-oc�1 bcC.irncca-,Y w mcudc iafocm.zioc pe-iainiac to.L
am 'a sole proprietor and have no one wor dDg for me.
( ) I am.a home owner performing all the work myself.
1
jNOTE.:plc be aaruc ri—wt k bcc:�cy,,,.,n w.bo=Vjoy P,—,,,w to do c°t¢-'^.^— cs'.-wro r Haan w-oric on a d..c1LZ of
jGot mert tti-G L7 --terra iG Wtt a the homco m,=rx:Oda c<cc the Etna,z7purteo.-rte them ac ox C_a lly Dees d—ai w be
eitplayc�tier a the 0==P�oG A=(GLt 52,n 1(5)�=pptinaoo by a homaoava fcr c 6c=----or pam;I c>=y--rd—the
lc-GA a.=-of am c=ployve under dw Wo[S•.ola Campomatio•o.Ad
I
- I unden�ad due a Ooyy of this mte1.31 may bo fl•-,-d d to tbo Dopnnmeo¢erindus:;J Aee&,Y M—or Ista+anoe roc the
eovcase—fielioo and tlt:u L xk c to undc soetion 23A of hiOL 152 an lad to the i=pasi6on of eimiaA pccsWcz
0Dousingor&riot orup to 5 IS00.00 andloc 6rq iyoc=v=oCup w roc yr3r e.Gd civil p=ills is t5c form Ora Stop Work Orde and a
(tm of.S I00.00 a d--y apic5l me
i
Foe deq.rtm:.�u.e only —
PcIM.)t NILMLcr
u
i.Cap"—_ Lot
Sig:—ttut of Lictsscc/Pctmiucc �Late
i
SECTION 8!-CONSTRUCTION SERVICES c
8.1 Licensed Construction Supervisor: ( Not Applicable 0
Name of License Holder: � e- ':1 l,_
i C
License Number
'y [
Address Expiration Date
nature Telephone
.MenwsE2cu. §J. a^�e<w czar Na�.t; ,., 4•'i' "1.
9..Reistere Homelm ro ement Contra"0' _ - Not Applicable]\❑ {(/\` `f
�V Vim^ V
Compan y Name Registrdtion um er ---
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCEA'RDAVIT(M.G L.c.f52,§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 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-near 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
r
i
SECTION 5-DESCRIPTION-OF PROPOSED WORK(check all applicable)'
New House Addition ❑; Replacement Windows Alteration(s) 0 Roofing
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [Q] Decks [0 Siding[0] Other[O]
Brief Description Pro se yy
Work: �'�� f.��17 1� ✓Z�tr
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
t�{ i �' ,-fit, "-� .. ,...-.r�.
Neva-house.anc Or di#toy xis:in ho rs�nT .com fete-tl a fol owiri y.
a. Use of building:One Family T o Family _Other
b. Number of rooms in each family un Number of Bathrooms_
c. Is there a garage attached? nn
d. Proposed Square footage of new construction. J0 Dimensions
e. Number of stories?
f. Method of heating?'C&cd V A 1 — Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. ,/ Masscheck Energy Compliance form attached?
h. Type of construction C((—
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 1
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.CONTRACTORAPPLlES FOR BUILDING PERMIT-'
I �f— , vie, .I,-, 'P Y ,as Owner of the subject
property G-2— � /
hereby authorize axli,— ` k- S 1lV l
to act o f, in all matters relative to work authorized by this build* g pe it application.
J
Sig ature o ner Date
I, sa(2 v 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.
,-s
Print Name
SgRutUr—e of Owner/Agent 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 CAL)0___
Frontage
Setbacks Front 9.
Side L' 3 R:` L2J R560( �
Rear i Lt
Building Height
Bldg. Square Footage
Open Space Footage % 2 `'
(Lot area minus bldg&paved
parking)
i
#of Parking Spaces
Fill:
Nor RE(Qk
(volume*Location)
A. Has a Special Permit/Variance/Finding ever been issued f r/on the site?
NO DONT KNOW 0 YES
IF YES, date issued:;act" a a33
IF YES: Was the permit recorded at the Registry of Deeds? L/�Nd � t✓iU. 1$`"� ��� �
NO 0 DONT KNOW ® YES
IF YES: enter Book Page' Document#;
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 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:
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 r NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Nort ampton `
Build -Qepartment
21�'Main Street
a ,
I n � o a aI
x m 100
�ton.Northa M A 0 06
� 5�+ ohe F j7 Fax 413-587-1272
'
mew
Iwo
APPLICATION TO",0`ONS RLt T,AL ER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
n
SECTION 1'-SITE INFORMATION
T s secttan to be com ted by ofFice
1.1 Property Address:
4o Wa
Zone Overlay D�stncf
RX
EIm S£D�stnct C6 Distract
SECTION 2-`PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
?j cylee�-vatLz' 47YC6-k�4"�' '4v vw A L '0C)'64f
Name( urrent Mailin Address L)
t
Telephone J�
Signature
2.2 Authorized Agent:
Ux
\
1, a nnt) Current Mailing Address: OtoJ,2-
!1 I J;
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 0j(j (a)Building Permit Fee
2. Electrical (0)(b)Estimated Total Cost of
oC�l� Construction from 6
3. Plumbing Building'Permit Fee
UV U
4. Mechanical(HVAC)
5. Fire Protection �t() f CO—)
6. Total=(1 +2+3+4+5) �� U Check Number
This Section For`Officiaf;Use Only
Date
Building'Permit Number. Issued:
Signature:
i
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0753
APPLICANT/CONTACT PERSON SARAH STULL
ADDRESS/PHONE 63 HAWLEY ST PLAINFIELD
PROPERTY LOCATION BLDG#2- 840 WESTHAMPTON RD
MAP 42 PARCEL 165 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE
Fee Paid
Building Permit Filled out
Fee Paid _
Tyueof Construction: CONSTRUCT SINGLE FAMILY W/ACCESSORY)
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License 071711
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved 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 Commis
2, 6 Z00-
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.
BLDG#2-840 WESTHAMPTON RD BP-2005-0753
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:42- 165 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:New Single Family House/W ACCESSORY BUILDING PERMIT
Permit# BP-2005-0753
Project# JS-2005-0478
Est.Cost: $75000.00
Fee: $851.25 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SARAH STULL 071711
Lot Size(sq. ft.): Owner: Pioneer Valley Habitat for Humanity
Zoning SR Applicant: SARAH STULL
AT. BLDG #2 - 840 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
63 HAWLEY ST
PLAIN FIELDMA01070 ISSUED ON:2110105 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT SINGLE FAMILY W/ACCESSORY)
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 2/10/05 0:00:00 $851.25
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo