35-031 (10) ._1
N1AR 2 9 20C'],
ENERGY CONSERVATION APPLICAT1444 FORM FOR
LOW-RISE RESIDENTIAL NEW CONSTRUCTION AND ADDITIONS
78U ���R i�ppedix { fif�dive 3/]/98) k.01NGINS�`1:.:
"SON MA 0"
p,ppt;urt f�.ame: �_ _ S;te f.ddre-ss:
P.ppl ucnt Fddress: C'tyfTawn. --,_--
Use Grou,:
Date of Appl cat on:
AnNirrp,nj p1--n.:
.
CO-r1t�3T4C.0 �"Y�'S�C�i�C1c flL1{ik .
U PrasrripiiLe P�cicage (`_imi?ea to 1 or 2- family vrood frt:-iE t�v�idings t,eatec: w�tt� fassil Pue's only)
Pac�,are (A throw KK from Table .15.2. lb): Heating Dtgree Days (HDD,,,) from Table J5.2 la: _
(Fcr items d. throug`:t ;.. fill in all values t`zt apply from Table J5.2)
a. Gross n><ti late.- sq. ft t. vJ21t R=Yafuc g
t. Glazing Areal �n k F.::. R :'a.c;2
c. Giezing (I DO x b-{-a) h. Basement wall �
d, C:w7ina 1 t-vat r �. ':iaU Perimeier
e- %a;hng R-value �. Heeiiog AFUS
PeFlorm2nce 'M-anual Trade CrrP d i
� (Limrt2d io •wo-o.. or metal .tamed buildincs only}
G;ma-tt-Zorre(from Fig, u6-2.2) Zone 12 ❑ gone
Attach rra -O`i K' )_-hec! 1 om r"ppcnvii 1,[cnd HVAC Tr,?De-Un"Wic-ris.heet, if appiic2b1c)
CJ [�StAs�k Saftvrare
A-ach Campiiance Paport and-Inspection Checklist printouts.
sysitrnS nnal}rsts OR Q Renewable cnerg`y Sa rtes
Attach Mass Re�giStared Architect or Engin-_-r Ana!ys;s
ALTERNATIVE FOR ADDITIONS ONLY-
a. Gross Wall +�iiing Area,, /O 2 Sn 't- b Glazing Area' •
_�_-, � GO SQ-ti c. Gl..��ng ffl(.1CYJ x b,-a}
❑ AE)D't T lON with ula2mg % (c.)up to may use 780 CMR Table J1 1.2.3.1 below:
MAX MLM U-value Minim, urn R valucz
FCnesfrat�on Coilirg WzlI Flaof Bastme-it Wall ; Slab Perimeter. Dept
t>:39 R-37 j P-13 R-19 : R-10 I R lo, a ti.
❑ -SU,%P'0(Jv," addition (greatzr than Gp%glazing-to wall and c^+ImQ gross area)
Attach -C.ansumer Information Form" from 7$0 CM-p, ,t,ppcn,fix B.
Official's Name: O`ficia]'s signature:
Applicztran Approved [� C)en;ed n Date of App a:affD iaf:
Roast.(S} Ivi vcilial. (prvwidt additionai de-talls as nesded on back, side)
C-az at-Area=-y-be-oft u-P,)Du�Gpammg ar Una-Am,_,
beeR(--s,ec-o DR.
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AMA' 01160
'b � �assacirusetfs
of Wart4amptan
<. DEPARTMENT OF BUILDITIG INSPECTIONS J
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 sup(: .: 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 fami�-
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
m de
understand the above.
(Home owner/re [dent'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
F E
Cri 3 of �rtrfllaiil}Itott
�Zc36Rc nerlle
u n DEPARTMENT OP BUILDfNC INSPECT)OI.'S ;
212 Train Street ' Municipal Building
INorthampton, TIass. OlOGO
WORICLIZ'S CONUENSA'MN C�SURkNCE Al=, ,,'sATjT
i
(liMen-x permittcc)
\%IlLb a principal place of businessfresidenc- at: - --
— (phone')
�� (st�.t/ci ry/st.a.tclri p)
do hereby certifjr, under thc.pa_ins and penalties of pcgury, ha)
( ) I am an employer providing the followine!workc's comocasadoo cove zge for 111y
i
emplovees worlong on tliis job:
I
Qnsuran=Coo (Polio Numb-cr) -- (r:•piradon Dam.)
( ) I am a sole proprietor, general conu-actor or homeowner (ccie one) z_nd have hired
the conuactors listed below wbo have the foilo%viog workers coE!oeru2aon pokles-
r�-) lea tc)
(i+ame of Cont:acto-) (Instrant;c Colnpan�•rTcuc; ?�`uut__, (`r_�:atra�_,
I
(Name of Contractor) Onsarance ComDanyiPoUq, \ttrncCT) (Expiation Dale)
I
I
i (Name of Coa=cio,) Cl su ancz Com 1pot; Number) (Expirstioo Datc)
(Name of Contractor) (Insuran(-- Company/Policy Numb r) (Expiration Date).
(na1� ddi oca!�xa.il accti-u�•cn c�clu�iaform :roc pctniains in.11 coo?-_C-O:. )
j O I am'a sole proprietor and have no one work-iog for me.
I� I am..a home owner perforrn.ing all the work myself.
NOTE:plese be ctvzre 1fi+•w{ )e hcm=,vera..bo employ pesoaa w i c=s.rjoo c rrpau-ork on d.•eILZ of
oat mote th_n t17x timtr is t�r�the bomoot nc rvid�or oo the Qainra z�purtca_a tbeen�-t ooe�.:.11y occsd_-rai m be
cixplor--s u`/—ibe..airs o=MP�m Act(GUI 52-=1(5)�=ppticzE n by a bom.oavc fc:bc=-'=or pctnit ra:y-idmee tbc
Ic;l n-L,,oraa crPloyx uod Td.o Wo,&r er Compoonation Arm
[and 7 Lt d that a oopy of thu mtcmcm may tx fo-.-.td to tho Drys,—a of i.&,,rid A.&= of -of Low, race for th.
cbva-�&e t'e•C31'00 and 01--t La=r to saarrc cove a under soezioa 23 A of MG1-151 da le-d to the impos'aim of aimiwd PC-16c
coaaitiit of a fiat or up to s I SOO.00 arwcc i$pcisoomc or up w ooc Y.c od c�i)pcv.ttia jn d.form of a Siop Work Ord-- aad.
r=0(5 1 C>0.00.day cPjnA tnc
For
I
Permit Numt-cr --
Lot
Sip�acurcofLi crmittcc �-� -- -�
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
IMZ"ecns ere rn Apr Wn1'V {wort raeto- A f Not Applicable ❑
Company Name Registration Num er —
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMP ENSATION':INSURANCE•AFFIDAVIT'(M-ML.i;-152,§1 25-C(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...... ❑
Vf 1 7 ffi> 11
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
No hampton Ordinances,State and Local Zoningf/Laws and State of Massachusetts General Laws Annotated.
omeowner Signature
r
I
SECTION 5-DESCRIPTION OF.PROPOSED WORK(check all ayOicabie)
New House ❑ Addition [ Replacement Windows Alterations) �] Roofing
; , Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [M Siding[O] Other[Q]
Brief Description of Proposed
-Work: N I-t9 R(re Us} [3E►1 Rs�iyt S l �4�J[� %1�7ht 12 y�'
Alteration of existing bedroom Yes No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes 'f No
Plans Attached Roll -Sheet
sa.f e w once n » co r o xlstenc iouslnst rcomQtet V C&0W, >In9:
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? `� Q
d. Proposed Square footage of new construction. ll Dimensio s 2'
e. Number of stories?
f. Method of heating? (-A> W i A I(Z ::::fhM2 ireplaieck or Woodstoves f Number of each
g. Energy Conservation Compliance. Energy Compliance form attached?
h. Type of construction LU006 '`KPr4e-
i. Is construction within 100 ft.of wetlands? Yes ✓ No. Is construction within 100 yr. floodplain Yes L-/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 L�
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED .WHEN
OWNERS"AGENT;OR"CONTRAGTQR APPLIES FOR.`BUiLblNG PERMIT
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.
I
Print ame
Signature of Owner/Aglft Date
d
Section 4. ZONING All Informati6h 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 F
Frontage
Setbacks Front 7. F4 0
Side L:!7'f�11' R S D : L:174-T R:3.S'Z5
Rear A
Building Height =- -
Bldg. Square Footage d0 � % ,
Open Space Footage % I
(Lot area minus bldg&paved
parking)
i
#of Parking Spaces
Fill: '; (i
(volume,&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES 0
IF YES: enter Book Page' and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued:
i
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location: t
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 r NO
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Nortfampton
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� N�tf� A�"I Lr�r
SECTION 1 -SITE INFORMATION l
This 'ctldn to m T e ffice
1.1 Property Address:
/0 C��6 r
��0 2
k
E m 5 Distract - CB D�stnct
L44 ,
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
S7,4X J 1,-<ejcAQs ;' i< PI �(e d�Ole(� &,t r 1/o2ei)CP
Name(Print) Current Mailing Address
Sg &
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
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
3 b, nib ,
2. Electrical O ob , (b):Estimated Total Cost of
> Construction from 6
3. Plumbing O ob a Building Pennit Fee
i
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+.4+5) O n U a Check Number
This Section-For Official,Use Only
Building Permit Number" Issued:
Signature:
Building Commissioner/Inspector of Buildings> Date
File#BP-2005-0499
APPLICANT/CONTACT PERSON KOCHAPSKI STANLEY J&KATHLEEN
ADDRESS/PHONE 81 REDFORD DR FLORENCE ()586-0897 Q
PROPERTY LOCATION 81 REDFORD DR
MAP 36 PARCEL 031 001 ZONE URA it
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: CONSTRUCT 448 SO FT ADDITION(ENLARGE 2 BEDRMS/ADD BATH)
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 from Elm Street C ssion
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.