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17C-273 (2) u 1r i f Ct ¢Tt1AMp�, O O Critl, of 'Torthaiiiptan z � j�r[assac3�uscits - DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municipal Building Northampton, MA 01060 S HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to act as his/her construction suhc :a: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 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 -- understand the above. (Home owner/resident's sign ture requesting exemption) I will call to schedule all required building inspections necessary for the building permit issued to me. Date Address of work location t of 'No rfljellllpfoll _ _- 9 E flaaawchatclta' �> DEP/ilt7ME11T OP BUILDr>\'C INSPECT lOI.S — 212 Main Strcet Municipal Building Northampton, Afnss. 010GO L < «'0PJCEIZ'S COINITENSATTON MSURANCF AI"I'L AVIT (li crnsxJpermJ tics) \vlth a pnricipaJ place of business/residence at: (phone:') (sit/ci ty/suucrzi P) do hereby ccrdi -, under the pains and penalties of perjury:,- :hat ( ) I am an employer providing the followine �vorkcr's comocnsZ:Jon cove ale for m� etnplovecs working on Lliis job: i an= Comr.� --- . (�su-r= ) (Pelie: ?:u.�r) (r;-pircior, Dpi:) O I am a sole proprietor, general contractor or homeowner (circle one) and have hired the consa(nors listed below wbo have the `OUO%vi P, worker's com:)tn 2don policies: 01;a lc of ContmC,or) (Insumncc Coin p m)-/hGUc Nun1*C7) (Ex:)rjuon D'Itc) (N;-mc of Contrzaor) (Lrns-wram-Z Comoanv/Policy \tuncrr) (txmrtion Die) (Name of Coamaetti;) (Insurance ComTan)-/PoUq- Nz mber) (Expirtioo Date) (Ttame of Contractor) (Lnstran Comcany/Policy Numb r) (E�xirtion Date). (aaach 6cct ifaco�-•to C-c!,a k iarorm.�Oc pcsta.iaisLz to.11 { ) I am a sole proprietor and bave no Oct wordDg for me. I am,a home owocr performing all the work myself: NOTE:plr-%c be et .ut t1*• +jrj.bcc.0,Oen..-bo cu play P�t<*as w -• -c uO c rcr¢v work oa a d..JJ_Z of CDC moct lbw L`xm t �is k`iD6 the bomowu OCr reside oc oO the V-o :b z�pune*+,�lbaeo Do(C-.a,_Uy xa:d=-cd to be cxirplaycs uoc c the t.�i c�a O=P=:.- ca Act(G L152-=i(5)),:.wd=600 by a bomco-Da fv:Gcs--.Or perma 2y-id—lbc j icgsl cta3u of an esPloye coder dso Worko,"Coa>pomatioa Aei I uad__-fe ma a ooaY or m;,Cnl-o's may be for'-Ii-d to the D p-ltm of lndvxria1 Ao dr x&Moo or 4a+u+ooe for tb. oovcasc vcifcaioc and th s C iliac to s«auc tovcrns:undcr s-O l oc 23A cf MGL 132 m Iad to the impcsi6oa of cimiasl pcaalSia coa LL:issg of a fiat orup to s 1}oo.00 and/or im�L OCup to ooc yc3r fad evil pccajm iO 6c form Of a Stop Work Ord=cad a fish Of S 109.00.d_y Lpj=me For dy,,,_, ,,=:t.J u.c only 1 Pcrml l N UML-r _- >`jap-—_ Lot n i" si 2&zt of Lic=zccJPcrmiucc J i SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone , Not Applicable ❑ 9 12egistereil'1.7ame�np�o�et'«ient�Gontractor ,,,�„�t; ��,���;�, ,;r z,�;w � ,: .��� Company Name Registration Number Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION iNSURANCEAFFIDAVIT(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 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 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 responsibility for compliance with the State Building Code,City of Northampton Ordinances,State and Local Zoni tate of Massachusetts General Laws Annotated. /Homeowner Signature-C r , SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House F7 Addition Replacement Windows Alteration(s) TRoofing Or Doors Accessory Bldg. Demolition ❑ New Signs [0) Decks [M Siding [O] Other[Cg] Brief Description of d Work: /Pro�o -�/p �L'—�1 ��.�, Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa: f°New oase�and°"or ad'dtlo��o_ezi`sting laous lac �oinpete tr'ea"Ft�iwlng: 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 L 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 AGENT OR'CONTRACTOR•APPLfES;FOR:.BUILDING:P.ERM IT I, 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 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 under the pains and penalties of perjury. Print Name Signature of Owner/Agent 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 r7f Rear Building Height Ofl Bldg.Square Footage % Open Space Footage % (Lot area minus bIdg&paved #of Parking Spaces (volume&Location) A. Has a Special Perm it/Vuranne/Findi ever been issued foc/on the site? �� ���� NO �0 DONT KNOKNOW *_v YES IF YES, date issued: IF YES: Was the permit recorded at the Registry nf Deeds? ' NO � DON'T KNOW YES IF YES: enter Book Page. and/or Document#: ' B. Does the site contain a brook, body of water nrwetlands? NO ( DON7KNOVV �_/ Y[5 IF YES, has permit been or need to be obtained from the Conservation Commission? Needs tobeobtained �~� Obtained /~k_/� Date. . . C. Dn any signs exist on the propert ��y? YES �~� NO IF YES, describe size, type and location: D. Are there any proposed changes to or additi ons of signs intended for the property? YES 0 NO �w0 ' r IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading, nn.or filling)over 1 acre orioit part nfa common plan that will disturb over 1acre? YES ���) NO P IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ` is n Deattmessaseonly} ty� �Northampton up,`srfI�3dI uittllh !Department t/� ue 'e ►t, 21 In Street � 4 g 2006 m 100 abrr� � AU 2 Northampton, MA 01060 ' phone 413-5§; -124� Fax 413-587-1272 a � r-;� �J .".rSpeCLf��„ � a3br•��r.,; t*'�'�.�^i�"r�°R �� � �'�' Y APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -'SITE INFORMATION ce 1.1 Property Address: ° > This sectwn to be completed i / jIlap mot UA1t Zone Overlay D,stnet / ���'•' �� ��/�- EI,t,S!»�©istrct � c13.Distr,c! SECTION 2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: //�� }� j / /_ 11 t11w t�4 TY, JLl/�J�''� --2 2 Z/L L i c� / Name(Print) Current Mailing dress: � � t Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION3--ESTIMATED'CONSTRUCTION-'COSTS- Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building T � -(a)Building-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=fQ+2+3+4+5) Check Number This Section For'Official Use Only _Date Building Permit Number. Issued: Signature: Building Commissioner/Inspectorof Buildings Date File#BP-2007-0228 APPLICANT/CONTACT PERSON DUPRE EDWARD A ADDRESS/PHONE 27 LILLY ST FLORENCE (413)584-0268 Q PROPERTY LOCATION 27 LILLY ST MAP 17C PARCEL 273 001 ZONE URB 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_ypeof Construction:_ERECT 8 X 12 SHED New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFO,AMATION 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 f m Elm Street Commis 'o 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. VVA r BP-2007-0228 GIS#: COMMONWEALTH OF MASSACHUSETTS Ma lock 17C=273 CITY OF NORTHAMPTON Lot: -001 Permit: Buildinq Cate og ry: BUILDING PERMIT Permit# BP-2007-0228 Project# JS-2007-000347 Est. Cost: $2600.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 5096.52 Owner: DUPRE EDWARD A Zoning: URB Applicant: DUPRE EDWARD A AT. 27 LILLY ST Applicant Address: Phone: Insurance: 27 LILLY ST (413) 584-0268 O FLORENCEMA01062 ISSUED ON:91112006 0:00:00 TO PERFORM THE FOLLOWING WORK:ERECT 8 X 12 S H E D 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 9/1/2006 0:00:00 $25.003026 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo