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32C-298 �r a o4S1iAMP�a } � � jlTilassacllicseffs DEPARTMENT OF BUILDING INSPECTIONS /? INSPECTOR 212 Main Street • Municipal Building ' Northampton, 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 supc., . ssor. 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 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 } a' i eF{OHO ?E C�7i of Pariliallip toil _ f n ~ � ��4�t ll(h RLfll6 I O DEPARTMEWT OP BUILDrj-,'C INSPECTIONS 212 Alain Street Municipal Duilding, Northampton, ATacs. 01060 W0 RICE It'S C0NIT E NSA n0N MSUR�NCE A1717ID \rl-j' (li ccvsxJpertn;tt`tx> \VIth a principal place of business/residence at: ��L� ���'✓' �-�G'z C (phone:') (snr...t/c�rj lsta.tcf�p) do hereby e ', under ic. ?-M' and penalties of PC --ha am an employer providing dic followim-, woriccrrs comncasabo;: covemgc for in) I etnplovccs «-orldng on tltis job: i _ r (Incur-� Comm-MI) lPclic:?:u_�ocr) --- ( :pir�tior, Dz�) O I am a sole proprietor, general contractor or homeowner (cu cie one) and Lave hired the conuactors listed below who h2ve the following workers com-nens2aon policies: (t;Zlmc Oi Conlrac,or) (Insuranc COmm1 i)-iii ohci \,u-m*--) (Y>:Jt J�^n I711C) (Name of Conaaaor) tuvJfZn ComnazyRolier Numn-:r) (Eipir,don Dar-) (Name of Connaao.) CInsZ>rance Compan�/Polic� N weber) (Expimaon Date) (Name of Contractor) (Insurance ComcaJSy/PolicY Numb--r) (Espitation Dar). (aaacb=%-4i ioc31 6c i ifa�to a�tud=iarormna00 paZaiaiaC to.11 oo�-sn�) { I am a sole proprietor and have no one worL-Lng for me. ( ) I am.a home owner performing all the work myself. NOTE:pl=.=be ay.zle th,,wtJe bccco.,a ubo caplay Pc'zom w do cr rear-cric on.d,,-U---C of riot moct th n ' tmrr in u'acb the bocnoowoe ruida or oa the p Dunes rapurtc , +th,,c f ox CaseRy oc<,d=r d to be ei:ploycs uncle ibc..aim=ers,�=oa Aa(G L!52:3 t(5)� pp[ir�oa lry a 6omooava fer_kic�.oc permit rzy e.id noc tre j Ic-p1 Mt "`of dao W OAcea Coc=pa= ion Act r uadait4ad tba a Dopy of dai.cmi.­d may tx foe__i.>d to the Df rtmco¢of tod.,sr;J A.d.=Y Off oa of 4za faooe[Of th. oova-x�vcrif t=ioo a_•id 11x1 L-.iltac to Lrrauc cov�TyL�under soc:ion 2 S A of).(OL 152 cna icy to tbd impomIIioa of ciminal PczilW,= 000s.i of 4 fiat or up 10 S 1 500.00 ar-dfor� �of up to Doc yc r e.nd aril pm,.hia is tSc Cofm of a Stop W of k.Orde and a fim of 5100.00 r riy 4Pi=me For•-c...wrt..,�..i v.c Doty PC7IIlIl Nt1IDtX'S Sigmaturr of Lia=iscc/Pcrmittcc SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: ) Not Applicable ❑ f, Name of License Holder: J t °1'� K U1 1'(A 01 C 5 0� 31 vr7 License Number LGt.� 5-i � -o P7 Address Expiration Date 49 C- Signature Telephone _� Applicable .❑ 9 fteitisteFed Ham lrriaravement Contras o ,ri...,, uo- PP Not A D 07 Company Name nn Registration N�7umber f (, -J `o C7 Address --T Expiration Date Telephoned SECTION 10 WORKERS'COMPENSATION INSURANCE 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 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 a SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable New House [❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[CI] Brief Descri-tjo(n,o�Proposed O�, 110 ' S1 i ,Ko t4r,,, sKI,,,t�'e S Work: rr Fes- / Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet Fa.- "'*',t ' M - „,: �+lew-hanse acrd or,:ad itior>#©exlstin :hOUSCi corn Cete tai"„ olowt> 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 C.ONTRAGTOR:APPLIES FOR,,BUILDING PERMIT -7� tL-L as Owner of the subject prope /I hereby authorizer") to ton my be alf,in all matters relative to work authorized by this building permit application. Sig ture-ol Owner Date 711 wt O v eA let 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 w _ "A f 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 f Setbacks Front Side L: R: L: R Rear Building Height Bldg. Square Footage % t Open Space Footage u % (Lot area minus bldg&paved I I E e -kin #of Puking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO Q DONT KNOW 0 YES 0 IF YES, date issued:; IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW 0 YES 0 IF YES: enter Book Page: and/or Document# B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q 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 0 NO 0 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 Q 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. A e City of Northampton Building Department 212 Main Street � . Room 100 y —" Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 a APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This sectront'ta be completed ti orifice 1.1 Property Address: Map 1=ot Ucut VCt y Zone OverlayD►stnct V: Elie St District -"i zCBD�stcict SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Na, rint Current Mailing Address 91-5164 - S 21S_L Telephone Sig ature 2.2 Authorized Agent: Name(Print) Current Mailing Addres : i Signature Telephone SECTION 3--ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building ��(a)Building'Permit Fee 2. Electrical (b)Estimated:Total Cost of` Construction from 8 3. Plumbing Building Permit Fee 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) 1- ;10 . U U Check Number This.Section For Official Use Only Date Building Permit;Number. Issued: Signature: Building Comm issionedtnspectorof Buildings Date BP-2006-1393 GIs#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2006-1393 Project# JS-2006-2063 Est. Cost: $8620.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Quinlan Builders 101707 Lot Size(sg. A.): 6882.48 Owner: THOMSON CYNTHIA LH Zoning:URC Applicant: Quinlan Builders AT. 33 VALLEY ST Applicant Address: Phone: Insurance: 5 Hillside Dr (413) 549-5474 (1 HADLEYMA01035 ISSUED ON.612212006 0:00:00 TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF 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 6/22/2006 0:00:00 $25.00114 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo