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36-194 (4) i o��t+nt�tpro r ^ C ify of Wort4aurpton L I $ � �lassacf�usctts DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municipal Building 'c Northampton,MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as }.is/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 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, 1 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 &5.,J.3 Address of work location v-IfI7 of �1>t� tl��ilt1}�tnit T 6 fit[a s A t fill sr tl 5 ' — "t r DEI'fJ"TMEIVT 01' E JILDMG INSPECTIONS 212 Alain Street ' Municipal Building 1."Orthalmpton, Mass. 01060 WORKERS COMTENI SATIONt INSURANCE A:rrznAVII \:pith a principal place of busiressJrc:sidence CIO heret)y Cerufl ;; unC'cl" the palls ano pCil 1t1CS 0! pCrjllr�', that O I am -m employer providing the .`ollowint `•�.orr_ers compensation covera c or my employees workirig On f 1115 job: (Insu=c: Compam') o c.NtlrnExr) ---- (Rx L'ir aoa Date) ! ) I a-m a sole proprietor, general cr o- 'rlor,CO1N'ner (Circle one) and 'gave iure-d the ContTi?ctors hsted below ti'ii0 i1- „ the :01 is% P� - e �8` �'or� s co,_ p n ion (1`:amc of Cor Lmctor) (�ncu' r]C� CClfl^?:i i� c - �i GhC'f �filjIl�i) Li0' Dal.,) (Namt of Con—acto-) (1a1Sd _P.C° 0??�':I�'/PO 1Ci �tl Iilt r) (1 ':r::i10 Date) (Name of Contractor) (Inslr nett Coop,a�;iPol;c Nusi� r) -x-1 :T do Date) - (Name of Contractor) — (ItuZ tanc Ce?L `iy rpolicy Numb,:-r) (Ei:pig tioa Dare) a&'it c<,aj Sk:'fit::;:!.^�-e�'_:::�t':-_:'i:'"•.•:'4:::1':�t� ._ ::I:� eli -� ( 1 mm it solC prUprlCtUi c':il'1 have 110 one 01 C4-�.1Il1-; for i11e. I "1111 tl home C\'1?1C" i)Ci�O`I?11h" 111 il. ii jf. I+O TIi:plc u be n}ry c Ls:.ti]e tx:rco.7r s 5 r.. �l ;,_ n;S ane�a.::°n m cr:-;?air ,,;:_(: not mete th:a throo units ir,t%irc+x Lhe F ��..ti r_ rr::::z or cx;'`u ._i z x_r cr r1 LF Gd a c o.{e xr'Xa12V c�ployv-3 u_ti cr t}r tiwa:a'_ccrx--:_i^n,r (Gr.!52�a l(Sll.a,:,'.i=aic:;iry a hnta oti xr for legal etalus of an employer und' tLn Workcls CkNm-t+er loon!.cL I u.-.dc-n tread that a copy of thin ctat=-s_'mx y bo fol—vd j to U--ji tn—,:of lru& trial Accjd�•y Off ao of i::a.tr,?:.o for tine coven ge vetificiioo and that L•lure to!a ir' :cc.iM 25A of?.iGt.152 can I=d to the imposition c;c ir_1 pcn!d;:a comisti'ng of a fxnc of up to S 1 00-00 art:''rr in:;:r urrtti:•1 of up to cr.- ::-.j civil,cnattia in dc 1c nn Of ft Str;, •'ni-Ort%=_r j firs of 5100.00 1 day 1gtin 0 m- . For dq uvxntsl u.o only i Jt nature cif i.ic�1 eJpr-..rnii;!c: - T : r.: _ r Sf=CT ONB CONS7RUCTIgN SERVICES 8 1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone �Re a bm m ue en Wowh"tra�ctor Not Applicable ❑ Companv Name Registration Number Address Expiration Date Telephone ECT10I 30 WORKERS' COMPENSATION 1N�NCE AFFIDAVIT(M:GL. 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 acccptable to the Building Official,that he/she shall be responsible for all such work performed under the buildine 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 fc�-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 �� EE r SECT.ON � W KIM 0P�R�RORGSEDaWORKz check�.all a Ii 'Jibhe I „=YS.?"�'}-�-?S.S. :.,�.�'�`�*�e... .a�'k��.a*tom..:.,.•.e Y. ....g•fi�i:: t.. .:: -,$,x"a'ws?m ; New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ . Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs Decks [ ] Siding[ Other [ ] rief 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 o 6a e­w 06HM d.or a"s ditvon t�eXrsting housing comp�:e--=e. TiUH0LbWing 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. Mascheck 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 Nc j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulati.ons? Yes No I. Septic Tank City Sewer Private well City water Supply SECTI©t� WOO iINRAUT�IORIZATION TO BE COMPLETED WHEN OWNEfS AGEN170 NTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property hereby authorize to act or 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. Print Name Signature Owner/ gent 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 Lot Size Frontage Setbacks Front Side L: R: L: R: Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved parkin;) #of Parking Spaces Fill: volume&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DON'T 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 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. Are there any proposed changes to or additions of signs intended for the property ?YES _ No IF-YES, describe size, type and location: City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone 413.587-1240 Fax 413-587-1272 f , APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1'- SITE I,NFORMATJON ���, µ���Th�s sec a,qn ko�b'�°'corrip�ete�zby�offic, � S 1.1 Property Address: W, Y Map 1� # � L� 2 Z=�' Zone (-:7P �x :Over) �str ct ' SECTION 12 PROP.tRTY"OWN,ERSHIPLAUTHORIZED AGENT 2.1 Owner of Record: STiL-&_-5 Name(Print Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone 4CT1ON.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 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) Check Number This Section For Official Use Only Building Permit Ncimber: Date Issued: Signature:' Building Commissioner/inspector of Buildings Date 788 BURTS PIT RD BP-2004-0529 GIS#: COMMONWEALTH OF MASSACHUSETTS a :Block:36-194 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2004-0529 Project# IS-2004-0748 Est. Cost: $1300.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sg. ft.): 70567.20 Owner: STILES ELLEN T Zoning SR Applicant. STILES ELLEN T AT: 788 BURTS PIT RD Applicant Address: Phone: Insurance: 788 BURTS PIT RD (413) 586-5121 (� NORTHAM PTONMAO 1060 ISSUED ON.-10130103 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL WOODSTOVE 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 10/30/03 0:00:00 1686 $25.00 212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 788 BURTS PIT RD BP-2004-0529 CIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:36- 194 CITY OF NORTHAMPTON Lot: -001 Permit: Bugd ft CateQorv: BUILDING PERMIT Permit# BP-2004-0529 Project# JS-2004-0748 Est. Cost: $1300.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq_ft.): 70567.20 Owner: STILES ELLEN T Zoning: SR Applicant: STILES ELLEN T AT. 788 BURTS PIT RD Applicant Address: Phone: Insurance: 788 BURTS PIT RD (413) 586-51210 NORTHAMPTONMA01060 ISSUED ON:10130103 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL WOODSTOVE 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-01< j ) 7'` 3 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occu anc A si nature: FeeType• Receipt No: Date Paid: Check No: Amount: Building 10/30/03 0:00:00 1686 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo