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25C-131 (7) ¢'SHAAfPl. ' of Narfhaniptan Z � � �iilassac}ricsetts DEPARTMENT OF BUILDD�G INSPECTIONS INSPECTOR '212 Main Street * Municipal Building ' Northampton,MA 01060 ,r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to act as hds/her construction Super.,SupC:­.,A so.r. The state defines "Homeowner" as, "Person(s) who owns a parcel on which he/she resides or intends to be,a one'or tW6 - 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 fie 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 r R E (rif t of aIIiptoli DEPARTMENT OP BUILDD\IG INSPPCTJONS - 212 Main Street ASunicipal Building Northampton, Mass. 010G0 I VVORIT-R'S CO'N'fPENSA770.N MSURA-NCE p,1'I'MAV1T (li ccnsccJperml tt:cc) %1.9 Lb a principal place of busioessfresidence at: --- I (su ticity/sZatclap) do hereby certify, under tic-pains aad penalties of pcgury, :hat { ( ) I am an employer providing the follo%vin-'lxvorkcr's colnocns_non coverage for my employccs «vorlang on this job: (in_cu-r-:nc Comzsm (PaLic:Nv..m�-r) -- :pirvor. D21) ( ) I am a sole propr,ctor, general coDu-actor or homeowner (ci cie one) and have hired the contractors lis below wbo have the following workers compen_t26on pckies: i ('NaMC Oi C0�t7tctor) (Instranc Cotnpan)•lt GUCt- NUJMhC') nllc) (Name of Connetor) (lnsirane;. C.omoanvi?oUc-V NLmiC2r) (-E%-D rrtion Date) (Name of Conrlacto:) (Insurance Compan)-/PoUq- Name) (Exaimaoo Date) l (Name of Contractor) (insuraszc_ Cop razy/Pobcy Nunaki) (Expiration D-- . (.Mach —A4 Oc=j ca.ifnccczr_y to i'c"d-informamoa pcuinias to all ooc rcco s) ( ) I.am_a sole proprietor and have no one working for me_ (t)'l am.a home oNvner performing all the work myself. NOTE_plea be tarot o.—.v) }c bac O.m,-.1 ubo auploy pcsom in c1�c• - csr�oo c rc,xa Boric cc.d—lL^;,of not macs ibex _=is is wmeh the bom.—.,=r r=id=or ea the p-vu zppu�th,:.�-c ox C^.-..r_tly ctcd-ni to be cavi-y`a tt the.-kcr z c==p - ca Act(GLI1 S2=I(5)).=pptinaon by a bomm=act fc-!ice«pc-ma r`7--id—tL- I-S-1 ct asc or to e:Pioyx coder d,o W wlkd.Cooapomalioa AeC 1 uad--md tha a oopy or thi.ma=mma m.y be roc.ard.d to tha Dcp,nm yx of I.+d.cuiJ AcedtoD'off oe or 1—ror Ih+ I oovuacc vcrirc3ioa and th_r L-iltac to caa=tovcn gc taadc socioa 23 A or MOL 153 na 1=-d to the iaxPO3-a6oa of c M;ZW pcn.+liio masi::s or r=orup to S I Soo.00:.dlor 6=pr�orup to ooc yc=r tad c%i1 pm.tia in t5c form or.Stop Wort Ord-- sad a 5=orS100.00 a d_y LPIM:2 M-_ on J7 ------ - PcT$tt Nt1IDt)C7 � n°-- tot i SECTION 8-CONSTRUCTION''SERVICES r 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone J. Zeaiser �� Not Applicable ❑ Company Name Registration Num er ---- Address Expiration Date Telephone SECTION 10-WORKERS'COMPENSATION`1NSURANCE.AFEIDAVIT{M:G 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 aadLocal Zoning aws d State o chusetts General Laws Annotated. Homeowner Signature r ,i . 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 [CD] Decks [[] Siding(01 Other[a Brief Description of Proposed ( Work: A{,k1( U71 � k i C )- d- ba WL . S tuns d'f Alteration of existing bedroom Yes No Adding new bedroom Yes ~No . Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet 6E1fMemft, ral i io #a exis ni i sln-(or,& a 1"M'e tam c a. Use of build' :One Family Two Family_Jz--' Other b. Number of rooms in ea mily unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construc Dimensions e. Number of stories? f. Method of heating? 4 Fireplaces or Woodstoves 0^Number of each g. Energy Conservation Compliance. Ma heck Energy Compliance form attached? h. Type of construction W nQ ff- �'pi u47-o I. Is construction within 100 ft.of wetlands? Yes No. Is constructio 'thin 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 6� I. Septic Tank City Sewer Private well City water Supply SECTION 7a­OWNER AUTHORIZATION-TO BE COMPLETED WHEN 01NNERS AGENT OR CONTRACTOR-APPLIES'FOR JJU I"i ERMIT 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 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. r Print Name Signature of Owner/Agent Date Section 4. ZONING All Informatioh 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 I Side L:i R:` I L:' = R:I ! Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bldg&paved I c parking) f E #of Parking Spaces — Fill: r volume,&Location A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO 0 DONT KNOW er YES IF YES, date issued: I IF YES: Was the permit recorded at the Registry of Deeds? NO 0 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 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: E. Will the construction activity disturb(clearing,grading,excayetion,or filling)over 1 acre or is it part of a common plan that will disturb over 1 acre? YES ,. NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. J l Build PP artment � 212 Main istreet o Room d0 1. AUG �onptA 01060 L-,---Ph-(4n-q_41_3-587-1240 413-587-1240 Flax 413-587-1272 DEPT 8 . IS APPLICATION TO CONSTRUCT,-AtTER',REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION.1,-SITE INFORMATION This section to be completed baiffce 1.1 Property Address Y k� k ry _ 3 {n'� //�� /�., verla�tstrict t 1if , V o lV OQl#.e �FIm� Disfnct � � wCB.p�stnct�' SECTION 2-PROPERTY OWNERSHIP./AUTHORIZED AGENT 2.1 Owner of Record: r- C wolf I -ter PS )'� lq6t.1,ke S,- �r Name Pri Curren Mailing Address: Telephone Signa-re 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 /f /�O F (a)Building Permit Fee 2. Electrical v (b)Estimated.Total Cost of Construction from 6 3. Plumbing BLiildingcPernitFee 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 -Signature: i Building<Commissioner/Inspector of Buildings Date File#BP-2006-0162 APPLICANT/CONTACT PERSON FORBES GWENDOLYN ADDRESS/PHONE 113 MARKET ST#3 NORTHAMPTON (413)582-6196() PROPERTY LOCATION 38 ELIZABETH ST MAP 25C PARCEL 131 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 7;96 tnz:a Typeof Construction: REMOVE&REPLACE KITCHEN&BATH WALLS&ADD CLOSET New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFgQ MATION PRESENTED: Approved 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 Commi ion 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. 38 ELIZABETH ST BP-2006-0162 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block:25C- 131 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2006-0162 Project# JS-2006-0249 Est.Cost: $1000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sc.ft.): 3397.68 Owner: FORBES GWENDOLYN Zoning.URB Applicant. FORBES GWENDOLYN AT. 38 ELIZABETH ST Applicant Address: Phone: Insurance: 113 MARKET ST#3 (413) 582-6196 (� NORTHAMPTONMA01060 ISSUED ON.8117105 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE & REPLACE KITCHEN & BATH WALLS & ADD CLOSET 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 Sienature: FeeType: Date Paid: Amount: Building 8/17/05 0:00:00 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo 38 ELIZABETH ST BP-2006-0162 GIs #: COMMONWEALTH OF MASSACHUSETTS Map Block: 25C- 131 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category_ BUILDING PERMIT Permit# BP-2006-0162 Project# IS-2006-0249 Est. Cost: $1000.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 3397.68 Owner: FORGES GWENDOLYN Zonim,::UPB Apnlicant: FORGES GWENDOLYN _-----�----- AT: 38 ELIZABETH ST Applicant Arldress: Phone: Insurance: 113 MARKET ST #3 (413) 582-6196 Q NORTHAMPTON i ,A01060 ISSUED ON:8117105 0:00:00 TO PERFORM THE FOLLOWING WORK.-REMOVE & REPLACE KITCHEN & BATH WALLS & ADD CLOSET 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:J✓�tt``� ,, D Rough: House# Foundation: �yLL /� Driveway Final: Final: , / , Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Roab;: Oil: 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 ~`°' i s�nature: FeeType: Date Paid: Amount: Building 8/17/05 O:OO:UO $50.00 212 Main Sheet,Phone(413)587-1240,Fax: (413)587-1272 Building Corrunissioner-Anthony Patillo � P `