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37-065 (61) City of Northampton Building Department . 212.Main Street e. r »� t.afiletn, - Room 100 q" r - Wortharopton, MA 01060 phone 413-587-1240 Fax 413-587-1272 r r _ m APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION t-SITE INFORMATION 1.1 Property Address: (' CCA T inecfomtaGecwmptefed 6yoffrce ' k (Q h l Ci Lr ih �M ; 'FISi.r3. - d3t of Uml nCf6I I ( \A Cil i.'li� oge _ #Areday Drstnct SECTION 2-PROPERTY OWNERSHIP!AUTHORIZED AGENT 2.1 Owner of Record: 7.10`ifir GnUq14iCO- Se kr N� /p\ c; ','i,CCL T 1 ) Nam � � Current Mn"Ig Adres LALIG f 'L Telephone Signature ' 2.2 Authorized Agent: lUiz: -VtMa g Addre k �; I Name(P - Current Mailing Address. y 13 hCSa—oSE Signature L. Telephone SECTION 3--:ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by permit applicant 1. Building / I C j i C1 c (a)Building Pen*N Fee 2. Electrical `7 (b)Estimated Total Cost of Construction from(6) 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5.Fire Protection rr� r/ G 6. Total=(1 +2+3+4+5) ," )15(o .gh Check Number d/pp � -- Thls Section For Official Use Only '-'Y Date Building Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date '2cIy2_ s Sa 'q 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 31Itjlo(12 ,<0 121tCM&C5.0 Frontage 0 ; : 0 • ' • Setbacks Front — Side L:—' R: L: R:. --' Rear Building Height --. Bldg. Square Footage Open Space Footage 1� (Lot area minusbldg&paved • Parking) S ' #of Parking Spaces o: "- 7f(Sift'i Fill: O § 3(., CT j 9 (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 0 DONT KNOW 0 YES IF YES: enter Book Pageand/or Document# B. Does the site contain a brook, body of water or wetlands? NO f0DONT KNOW © YES IF YES, has a permit been or need to be obtained from the Conservation Commission? ' Needs to be obtained © Obtained © , Date Issued: I C. Do any signs exist on the property? YES © NO fa • 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,excavation,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES © NO 01;' IF YES,then a Northampton Storm Water Management Permit from the DPW is required. SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n. Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition ❑ New Signs [7] Decks [[] Siding[D] Other[p] Brief Description of Pryry, po ed pp Work: Mebtfilll(n n c� t,,oci.C/ St"; - Alteration of existing bedroom Yes Y, No Adding new bedroom Yes X., NQ Attached Narrative !!! Renovating unfinished basement Yes Y No Plans Attached Roll -Sheet /l 8s tal rind stl r OWmil: 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 a Number of stones? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy COTservation Compliance. Masscheck Energy Compliance forts 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--OWNERAUTHORRATION-TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTORAPPLIES FOREUNDING PERMIT I, 141+V. �u-r 11 ,as Owner of the subject property II hereby authonze vt k flit( �i✓� to ad onpw behalcirrantiatt r veto work authorized by this building permitapplication. / C` if,' (D(o Signature of Owner Date j<Ir * 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 and sand penalties of perjury. yj Print Name" �, -7/5•39; 7 /f eL, Signature oerlAge Date 4. SECTION 8-CONSTRUCTION SERVICES 81 ens C. s ellen S�u..; 's•r Not Applicable 0 // Name of License Holder: , lid t,,,al "io\„ _ � License Number Address —.. Expiration Dale .-- Signature Telephone •_-v sY'.ie`r'Yn 'back i Capra 4 3 ;": rE74 WJ Not Applicable 0 Company Name Registration Number Address Expiration Date ... Telephone SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT DA.G.t.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 buil ' g permit. Signed Affidavit Attached Yes No ❑ The current exemption for"homeowners"was extended to include Qwner-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 10833.1. 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-veer period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official,on a fern acceptable to the Building Official that be/she shall be responsible for all such work performed under the building permit As acting Construction Supervisor you!presence on the job site will be required fromtime 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 he liable for persons) 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,Smtc,.w. . al'ening ws and State of Massachusetts General Laws Annotated, Homeowner Signature „slim° , ase\ H d are (EIfg IIf Aartf(&nt}rtQit • �_� ca• tr �aava�hnseHe i.l -= 1— FIJI 74 .DEPARTMENT OF BUILDING INSPECTIONS =_a , INSPECTOR 212 Main Street • Municipal Building —/ Northampton,MA 01060 v� 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 supx.isor. 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 1, understand the above. (Home owner Iden is signature requesting exemption) I will call to sche e all required building inspections necessary for the building permit issued to me. Date (O/(70(s Address of work ,, // location ( a(y, P�lac-L er /�h /( / 1(cr,v,c, tMii- v(O(i7 The Common yjealth of Massachusetts siepartment of Industriatelethtents • OffireestiaresttratIous _ • PO Cfreishbigron Street • Bonen,Mass. 021.11 - 'Workers'Compensation Laurance Affidavtt r Pros– cta-LQ iocaten- 04,1, aftk nr, (tL-Th ) A- ot)cs, lisoneirj6A 0 I am a homeowner performing all work myself 0 tam a sole proprietor and have no one working in any capacity FP I am an employer providing workers' compensation far my employees woriang on tttis job. %/,,:t1,49.Winina:;;Cbbr,t,,Sr,dttc".33 ;T:7; r rr '14131S:49845" 1.,,S63-33'1-iMAT I am a sole proprimor, general contractor,or homeowner(circle one)and have arra the cantor:ors /inn below who have the followmg workers' compersanon polices; tf,Xgirc; em.te..ase`e.e ' ' hone* r . -4)(,‘?"-,4147." ttft4-1 1.2;n:;$1..*.ali,;•:Z.ItiZt7a?:9?- :...; illStrinsietesp=MM'-'44,1,--n",757S,2CSe.: , „, failure to secure coverage es required gator Semen:SA a&COL 1S2 csa lad to Ite Imposinga ertateat pension of an up test.swaxo tatter sot rout itnpriatreanot al wen 22 don poultice in the form of S.STOP WORK ORDER sods Dag,(S100.40 s day agstot ale- andetteeett that s Copy of this stattosseet may be forwarded ea the Ofilst of Investigations of the DIA for coverage verification. I do hereby eerdp,tender ate paha and amities o‘perjvtry that the information provided above is woe and cony= Signature Due Nun name Aertifi C;. i/1/4/54--i phoriecti/t).45-- g—f2cis- oillcial use only do oat write le tat ono to be completed by dty or tows*Mar - city or tont - -— permit/license 0 raleadistg Deparcnnat - OLietesieg Bawd 0 Seek Wiser/Am response is required * 0Seletratenis Office OHS&Deparosteet :tsetse:perseva phone t; rlOmer (.alour,PIA) MA Construction Supervisor#CS809989/MA HJC#148198!CT 111C.556609 - Olde Hadleigh Hearth & Home Center, Inc. 119 Wil!imansett Street,South Hadley, MA 01075 Tel(413)538-9845, FAX (413) 538-8753 WOOD STOVE INSTALLATION CHECKLIST ce ' { # 12q 3 Permit A building permit is required for the Installation of any solid fuel burning appliance. The building permit and installation inspection Are limited to the stove installation and not to the stove construction. Stove A) Type/radiant circulating R) Manufacturer (2r z test label O /0'd- Ort-,-4.--Fry WGLtM 4.12-( d AL ( 'g� after July 1 , 1975 only) Name/Model No. /ylLM k�� (/53�Collar si _ b� ` A DimensionslHeig t ()Ay length/9 Width, .7 Chimney A) New l� --rte,,-44 gExisti , e) Size (flue area) —� C) Other appliances attached to flue (Nu, .er and flue sirs) '--- , D) Metal (Manufacturer—name and type) L _4,6. 00 H'.io / „t.P'lril ✓7-4Nftt f) Masonry/tined V.f Unlined Flue liner , ,^ �p///���l\1 (type E manufacturer) F) Height (refer to diagrams) Ji-�i.Gr<lW L`� ,cap — •a::` ../.) JIUS HEARTH `. CHIMNEY HEIGHT VL t j fj 564;6 _ ynn 4JWM Hearth(min. t hr. fire resistance} A) Materials trnca'Y to /ld D 8) Sub-floor dimensionsnsconstruction A g.. tjra� C) Minimum (refer to diagram /r Clearances and Wall Protection(see stove installation clearances chart __ 6 4 my A) Type of wall protection provided " - 1 .4....�... .. 8) Clearances (refer to diagrams) __,Kt >7,—- 4' ,..1 `fir FIREPLACE CORNER ^! PALL/CENTER