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25C-025 (2) pQ`'CH�A1pJ0 � � �lassac}�nscffe of Wort4ampton 6 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 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, 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 'zflF of Lill p - 6 f5I[S 1 A(11115[f la t 1)EPfu2ThiEArr OF BUILDING INSPECTIONS 212 Man Street ' Municipal Duddin9 Northampton, Mass. 01060 woruC,R'S CONTENSATION I- SUIZANCE /IFFM AV1.T - (]icons^c�r'%'rmitt�c) ti:ith a principal place of bus.resslresidenc do her6uY CCI-LLIY, L:1:'f:l- dic• ails 1)C il<ltl' S of pCr�tl(y illat_ I a D an employer provIdIng the i011O`.'.,im: v'-o t;Cr`$ CompensaU0I1 cove"-2'-'.0 For IIly enlplovees working, on this job: (lIl.SuI3S1G' COLT)2Il}') �:C C �ti1_1t7Cr) ---- Y�. -I 7^A Data) j I awl a sole proone tor, gen°ri cn�nmac`cr hOrleol. oer (Clcle Oct) and hired th,-, con—uactors listed beio w0]0 it i}1? `O I L: "0FkP-"S CO'0e11�3d0it 0!iC:cS: (-Na-mC of Corm—.Ctor) CCIIlL'-:-'y/7011cf T�1IT1�Cr) .+:.1on Date)- (Namt of Contractor) (11 s,Ir ncc Con a.1v(Pc!ic; Ntnirr) (1= ';tioa Date) (Name of Contractor) (II1s�,-ulcn Co L;_sril o(ic. NnmtxrJ x; +.ciao-Late) - _ ^__—� !,:;...lor Late) (Name of Contactor) (Iosur- fez- Com 7.y oli.,y Num?.^*j (. `�'�" j dill ZI l:On?e ov,"I'r ?:OT,:plc-=&C tc ntv c t!:ar.l i]c F <rc: lr s ,c: Uc<.1 . r1v c4 x::_: m cr;-gat c,;; - •cl!i 3 not Lmcc lli u throo units i 5 „acs y n horlco«-lcr fcr a Gcc c cc p-r t:e_ <rtie (G,..S_�_.( 1;;.-�:�iic._. ._ legal aatuc of an auployor under tt/c Wcv Yclt l a2^,d itiOn .cL I undo--ztaad thAt a copy of t}u r:.y hn to tt;o[ytiuruxrsz:of T.c�LStriJ An-id-=;31 Cf;:oo of is +r =o for tlx 00-r &c.vr-iiclioo ald tl t f_ilurc to t-_,:.ut c,3%-T--g7,to 1-:zcC.ic^25A of MC-1,152 czn Ic=i to the LnlpoSltla ooaiutng of a rlrr of up to S!SOU.CuJ n;�'r i-:ilr;vr. c; n(::p to er..}- r.:.j civil pczultiu in lc ii nn c•f a S!c- `•}'c x. _.^1 a L1W ocsloo.w s day tpawti rat. . _ iur ciuncztil 11-oily (� Gc� L� C 1 -- it1 _'-- t r Sirnnturz of..icc, Jilcrmittre- _ .._ i F 77777777= ;z SECTION 8=CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone .Re a>e` z�m: m r: vemen -ont;actor Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G:L.c. 152, §,25G(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...... ❑ sn' 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 "homeown r"certifies and assumes responsibility for compliance with the State Building Code,City of Northampton Ordinances, S to and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature ''`�'`-'� SECTIONS ©ESCRIPTION OFCRROPOSED,WORK(check atl;applicabYe) m New House ❑ Addition ❑ Replacemeit Windows Alteration(s) ❑ Roofing ❑ Or Doors `jam Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ) Other [ ) Brief Description of Proposed Work: ta 9 L7 W "(,/t Alteration of existing bedroom Yes 4-1 No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes _ C No Plans Attached Roll 0 • Sheet 0 6a 1°f .eW house orM dd"isti.on.t eki'sA ng housing comp e e thefo°llowing: 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 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 OWNERAUTHORIZATION ,TO BEICOMPLETED WHEN; OWNEkS�AGENTOR CONTRACTOR APPLIES,FOR-BUILD NG PERMIT on : y I, L� as Owner of the subject property hereby authorize --� O Vit to ac; on my beh f, in all matters elative to work authorized by[his 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 un er the pains and penalties of perjury. Print Name Signature of Owner/Agent Date Section 4. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION Existing Proposed Required by Zoning This colurrm 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 arkin ) #of Parking Spaces Fill: (volume&Location) A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW ✓r YES IF YES, date issued: IF YES: Was the permit recorded at the Registry of Deeds? NO DONT KNOW YES IF YES: enter Book Page and/or Document# B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES IF YES, has a permit been or need to be obtained from the Conservation Commission? Needs to be obtained Obtained , Date Issued: t�--� 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: S City of Northampton � ���. Building Department 212 Main Street r Room 100 r elm Northampton, MA 01060 phone 413-587-1240 Fax 413-587-1272 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION'1-SITE INFORMATION a `Thiasectton tQ be completed by office 1.1 Property Address: ;t , /° "'`-`A V 0 -�'�'LP�r1�r►f if LAG(� Zane Orrertay District 4 1 ,,�fl70.Str D!S'tnLt � 'w C${)ISt17Ct , SECTION'2-`PROPERTY'OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Name(P' t) Current Mailing Address: Telephone Signature 2.2 Authorized Agent:g Name(Print) Current Mailing Address: -7 -74, 3 u, s` Signature Telephone SECTION 3-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building '1(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 = (I +2 +3 +4+ 5) Check Number' This Section For Official Use,Only Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date • 22 NORTHERN AVE BP-2004-1328 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C-025 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2004-1328 Project# IS-2004-1995 Est.Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.ft.): 5009.40 Owner: DUSHAME LAURA L Zoning:URB Applicant: DUSHAME LAURA L AT. 22 NORTHERN AVE Applicant Address: Phone: Insurance: 52 ORCHARD ST GREENFIELDMA01301 ISSUED ON:6128104 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS 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 6/28/04 0:00:00 247 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo