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17D-060 (4) • I g (rztlr of Wort4ainpton z I�RS>fRChliSttt4 - DEPARTMENT OF BUILDING INSPECTIONS /= INSPECTOR 212 Main Street • Municipal 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 iris/her construction supc-,4 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 �J I, G��/�✓r �y�d�! 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. 0 Date 2 4V, ,?, Address of work location )Vl&U4,?N'_ A& t t hT •��.°���°tiff � - 6 {s�iseRCflnsctte � —. s m DEPAR'I?1ENFF OF LUILDRJ G INSPECTIONS 212 Main Street ' Municipal Building IN'orthampton, Mass. 01060 womCtiR'S COMTENSATION INSURANCE A i t c�.vn --._-----_._-__-- (lsc-_nscJccrnli;t c) vnt11 a principal plac_. of businesslrc: ecnce I I ' ? tCS Oi C{O 11cf by Ccl-LU'. 11I1: -pains rid peni ' a., ( ) I am an employee- provlding the ;ollov,'Ml: ::ort_ci's col Vcnsauon cove,:-.: e 'or ;ny employces working on this job: (Insirancz Comp.=") ( Clio;NU_nber --- (Expimdon Date) ( j I am a sole proprietor, gen°ral c:)n=,_cT o ilonlco��ne (cL'Cle One) and 'gave aired t.Yi:° contractors listed belov ,�tlo il-.., the of}c:v:;v -. .,,'s compen on ;o! c:es: (Nla-me of Contato cr) (Casa arcs Cann-:;?:Polio, Nulnlxr) Date) (Name of Conmctor) -- Qns-,irancc C=m:)an v/Pelicr Nu ntrr) (I >:p ^tiny Dale) (Name of Contractor) (Ins rand Co :n.;t?olio: Nulnif-_r) x;.'.ratica Date) - (Name of Contactor) -- (Ios, Lance Cetnr J v Policy Numb-r) - (I:::ri !tior. Dare) (eILl C�1.S.d�IJCY^.17 SI._Cf:....'_... ::7:.:_..�..:...:'Y";1';�(:r- ._.::I::,'._eli..�..:_._...•l ( 1 'Uil a pole prapm1 "")I iiii! i1SVC IIO -)11,,3 KOC .iii`; tol- n,". 0 ) I :?ill a home Uo'iinc ii"i:C`I?11I7 ail i!. iii'YS If. ?410-I.1::plcasc be atrarc t!s:.ti�:ilc 1 t;so«zr a«;rc c pI Ir c n di <<:�nt�cz.ccn r_ n cr.c,;a not uxec tie n ti�too units in«t dt x 1 :a•.:tZr rn ,u a;c _:.:� ^t•-rt<r r1 ihcC.c e-nc<hers 11}'crr•'::rC:c caiploycs un.�Lhc wocr',rz'_ar^ :ei'n Pd(6t.!52 s!(S j!,z( •iir..ic:•,by s F.otaco«xr`:ore L"=-=CC p:r.::::: ICS 21 etaiue of an Qaployx undertLo wo tier COi,wr�Iion f.CL I undczi2iad th+!>copy of ttii cutcis•r.:iy t',o favr�vdod to tl»lYtiurt�rn:of Inu+i.zriJ An�'�tj<%i icw oI:::%•.v?=a for Ux cov=&--va f Glloa grid that feilur_to r-=,:rc coy r ux--k.zccic 25A of MOL.152 can lc--d to d-i•njraSitioa of c _1 pa al.a comis2mg of a f] 'q up to S 1-S00.00 a:r&'r in:pr vx-r;-;1 or;;p to cn:)-'t;e:.1 civil csutt u in do fi nn cf n Si­,, f rl oC S l 00- i isi !AM. F,d'p tnw%esJ uic only Pcrrni Nt:ultx:r MI. —- — -- Siw urc t�f I.iccn: :JPrrm;ar.: i r I SECTION 8 CONSTRUCTIQN SERVICES ;? 8 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : i License Number Address Expiration Date Si a r Telephone �y I Re e.e . rn rrr _ ve..' n.=C n racto Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10 ,QRKERS' COMPENSATION INSURANC-E.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 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 fo-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 s permit. The undersigned"homeowner"certif s an as mes responsibility for compliance with the State Building Code,City of Northampton Ordinances, State and oc Z a 'a/ A/and State of M)aasssachuse�tts General Laws Annotated. Homeowner Signature SECTOaDE�� IPTIOIIROPOSEDYVORK- check=%11 a I�cafile ' New House ❑ Addition ❑ ReplaceMeo Windows Alterations) ❑ Roofing ❑ Or Doors )d Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes /' No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0 - Sheet 0 f :e f>totrse e d orM ,�d'iti:on�t weeX[ fin - ff-5 n - e-e.. 'he fal.lowrn a. Use of building : One Family Two Family Other�� b. Number of rooms in each family unit: Z/9 Number of Bathrooms T c�—) 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. Mascheck Energy Compliance form attached? h. Type of construction Arz � L?j7� i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 r. flood lain Y y p es ZNo 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 EC70 1N RTIORIZATION `TO BE COMPLETED VYHEN OWNER E © CON' RACTORAPPLIES FOR BUD(I�G PERMIT IL` as Owner of the subject property hereby authorize �� �, � to act on my behalf, in a atters relative to work authorized by this building permit application. 71e13. Signature of Owner Da e 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 Si of Owner/Agent Date Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This column to be filled in by Building Department e Lot Size Frontage Setbacks Front / Side L-1,57 R: L: R: Rear Building Height / Bldg. Square Footage % G4 Open Space Footage % (Lot area minus bldg&paved arldn #of Parking Spaces Fill: (volume'&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DON'T KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO A/ DON'T KNOW 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. A e t ere any proposed changes to or additions of signs intended for the property?YES_ No IF YES, describe size, type and location: j City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING :SECTION 1 SITE INFORMATION IYQ1e iGO11I let by�$fliice 1.1 Property Address: 'C �j�/1�✓ /�//Jy^ / � r� ,y;:�``r 41'G '�+�� ne '�, t � y .���� x SECTION 2,=PROPERTY-6 UTHORIZED.:AGENT 2.1 Owner of Record: //y��//p ,//^�/y/jam////•• J/'/ryJ�'Jr�f� ,/,p`-- ��//� //y}// ///J//ry/{,J/.�// Name(Pri Current Mailing Address: Tetee hh n, ignature `7�/ f -P' 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION 3- ESTIMATED CONSTRUCTION-COS S Item Estimated Cost(Dollars)to be Ortly completed by rmit applicant 1. Building r r� Ea)Bualdmg Permit.W° 2. Electrical J C� (b)Estimated Totaf Cost-of Cons�truction�from t 6 3. Plumbing B'u�Iding,PermitFee, 4. Mechanical (HVAC) 5. Fire Protection 6. Total =(1 +2 +3+4+ 5) Q �' -Check Numter (015, 1 a This Section�For Offictat:Use°Oril Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 20 GARFIELD AVE BP-2004-0703 GIs#: COMMONWEALTH OF MASSACHUSETTS Ma:Block: 17D-060 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2004-0703 Project# JS-2004-1015 Est. Cost: $2500.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 28880.28 Owner: DRISCOLL EDWARD A JR&MARY F Zoning: URB Applicant: DRISCOLL EDWARD A JR & MARY F AT. 20 GARFIELD AVE Applicant Address: Phone: Insurance: 20 GARFIELD AVE (413) 584-4333 O FLORENCEMA01062 ISSUED ON.12119103 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPLACE PATIO DOOR 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• Receipt No: Date Paid: Check No: Amount: Building 12/19/03 0:00:00 2658 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo