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29-286 O¢��MpTO ;..Lzfy nf Wort4amptun z $ ilassac3�asctts DEPARTMENT OF 13UILDINIG INSPECTIONS I /: INSPECTOR 212 Main Street • Municipal Building North,unpton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCNIR 108.3.4 to act as i:is/her construction sup(:.,,so.r. The state defines "Homeowner" as, "Person(s) who owns a parcel on which he/she resides or intends to be,a oweor tiwo famiy - 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 buil ding department foi the City of Northampton wants-any persons)-who-seek-tv 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 buildine 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 L 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 Crib Qf {Orf11alliploII - [ o DEPARTMEITT OP 11UIL.Dr>\C INSPPCTio?"s - j 212 Alain Strect - Municipal Building Northampton, Afars- 01000 . .... .... - WGIUCEI IS COINOENSATION ONSUR—NCE Al'i JJJf .�1A' (li ccnsxJpera>;tfcc) ,kllLb a principal place of busiaessfresidenc- at: - - - (phone") (sn-rr.,t/ci rr lszau/a p) { do hereby certify, under thc.pasns and penalties of perjury, ihai ( ) I am an employer providing die following!v.orkcr"5 comocnsabo, covemse for Iny elvptovices Nvol�zng on Lies job: - (Cesar-mac Coax ) (Folic:K-u—LY I) -- ( ,piration Dzz=.) i ( ) I am a sole proprietor, general contractor or homeow-Der (ci:cie one) and have hired the coairactors listed below vqbo have the `ollowing worker's GOC20eP—taaon pOkles, j (N=-, O- Cont=c-'Or) (In--urancz Comoaalyill oUCi NU-Mb::) 1111c) (Namc of Conamclor) (l.nsuazcc Comoanvv?olie: N1un62r) (1=.vDira6on Dale) (Name of Con=do;) (Innlrancr. Comnan}-/Polio}• Namber) (Expirraon Dalc) (Name of Contractor) (I2a1ra.nc-- Compa¢y/policy Numb-`r) (E p'bon Date). (arsdocil .itn�.-.-- -}•ca c�cv af«m�on pervIa:ng to.0 oc,�-r�:a) _ O I am a so-Ie proprietor and have no one working for me- ( } I am.a home owner performing all the work myself. NOTE_plesc be.wart t-x +-1::}o hcmca ivc s v.'bo ley pe= Des w do -• cs ciao a rc-zir work as.d. th--Z of oat meet tl`n ` it pis is�c1se's the bomoo.�vc raider or oa the Umra6,�pusten =t2ra c c ox =>r-!iy eC'cid.-ed to t+c ei�loye"uaGc the�.ui of - ---*ea Act(GO 52..-.1(5)).appU=t 6 a by a hommo-oa fa a 6cw- -a pa-mit=y a idmc-.e the I- ,.l clan=of en Moyer wader dao Wor$cl,coo3pomatio AeL [uadczzaad that a Dopy of thin car.cmua may be for�.n+•da.d to the Dopenmco¢vrIn6u:ri c!ncolwsYj Offioe cf Gaa+�+oco ror t6. �`�'o"e�^eif etioa and dLt L-ilta•e to LC=M toveraSe t>adc",lion 25 A.of).iOL 152 Qa lod to the inPoz�ioo of c-=iaal pe=liie coau:.i:ta or a fioc or Up to s 1}00.00 azid'or of up to Doc y-....-d c vu PCO-16a is ttx form ora stop Wort;Or•dc and a fl=of 51 DO.00 a d_y apjJ351 me For only perMjt NumbC7 _ Sipatuyc f-Lic sc: Pcrmitt�r_ ' > I 1 4t SECTION 8.-CONSTRUCTION SERVICES t 8.1 Licensed Construction Supervisor. Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone grRe"°usereotrrTmave'r[erGortr.ctot: � Not Applicable ❑ Company Name Registration Num er - -- Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION'1NSURANCE--AFFIDAVtT'(M.G L.c.152;§f25CM) 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 r SECTION 5-DESCRIPTION-OP PROPOSED WORK(check'aliapplicabie) New House ❑ Addition ❑: Replacement Windows Alteration(s) ❑ Roofing Or Doors D Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[0] Brief Description of Proposed Work: Ps rht: 'k i,N Ili Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6a_ €Neviotase°arxcor�actd�t�acl Lexcsttnc>r-lionsina- compfettthen[la�ncritq: 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 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 Pdvate well City water Supply SECTION 7a-:OWNER AUTHORIZATION=T0_BE COMPLETED WHEN OWNERS AGENT OR CONT.RAGTOR APPLIES FOR.BUILDING PERMIT 1 as Owner of the subject property hereby authorize to act on my behalf,in all matters relative ork authorized by this building permit application. Signature of Owner Date 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 r the pains and penalties of perjury. JIM r Print Name f f ignat a of Owner/Agen DatA c 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 Side L:' R' L:l R:' r Rear Building Height —` Bldg.Square Footage % �— Open Space Footage % (Lot area minus bldg&paved parking) #of Parking Spaces Fill: (volume*Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? N0 0 DONT KNOW 0 YES 0 i 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 Q 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 Q 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 I; 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 Q r NO I; IF YES,then a Northampton Storm Water Management Permit PPermit from the DPW is required. w . e City of Northampton t 1. Building Department 212 Main Street se er ti Room 100 Northampton; MA 01060 w�S s o pct raf PCair fi phone 413-587-1240 Fax 413-587-1272 Pt� stfiat�s ,y & _�` z APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: Thts section"to be comp b ieted yof#ice „1 ,�>r'1lt"�f� vi 10 Zone Oyerla Distrrct Elie St Dlst tct CB D�strici SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT 2.1 Owner of Record: N me(Print Current Mai' ` Telephone Signature 2.2 Authorized Agent: OCT 2 4 I Name(Print) Current Mailing Ad - -- Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item - Estimated Cost(Dollars)to be Official Use Only completed b permit applicant 1. Building (a)Building Permit Fee � Z,� 00 2. Electrical (b)Estimated Total Cost of Construction from 6 3. Plumbing Building.Permit Fee GCS 4. Mechanical(HVAC) 5. Fire Protection 6. Total=(1 +2+3+4+5) Check Number This,,Section For Official Use Only Date Building Permit Number. Issued: Signature: ' Building Commissionerlinspectorof Buildings Date 28 PENCASAL DR BP-2006-0456 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 29-286 CITY OF NORTHAMPTON Lot: -001 Permit: Buildinq Category: BUILDING PERMIT Permit# BP-2006-0456 Project# JS-2006-0678 Est.Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 10715.76 Owner: VENNE THOMAS Zoning URA Applicant: VENNE THOMAS AT. 28 PENCASAL DR Applicant Address: Phone: Insurance: 28 PENCASAL DR FLORENCEMA01062 ISSUED ON.1013112005 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 10/31/2005 0:00:00 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo