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25C-217 (2) �'Ct1AAlP�. Grity of Xort4auipton �1833ACI}118[tt5 5T1 -, DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municipal Building Northunpton, MA 01060 r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as iris/her construction supc�­ ,: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 �1tV�Nl�T� � z flI all IpfoII { 6 Ei�asaxcfln6cfls l L ��1 -- 1iF,YP,R"r?„EN"1' OP PUILDII�G INSPECTIONS -m 21 MT . . ` 2 nuI Street Munlclpal Budding Northampton, — Northampton, MRSS. 01060 NN'ORICEW S COMPENSATION INSURANCE AFFIDAVIT �;rith a principal place oI 'bu��n���.%r-�_;�,[: eucc :.? M.as5 vt 3 }0 �� � �VF_-VLftin.c.f �"�- ,S�-1F �, .�ALLS ([;h ,[, �'�' � aS `� �}•� 5 do I ewhy Gehliy, Mai the i7C"121i1:..> Oi pC'tJlli�' :IIF!i_ 1 X111 an enlp!oyn prov,'Kg the ATo"'iny '„'O:kWs com wns' ,2(1,.)Ii COQ� .:,C too :iiA' clllployccs "vol king inn oll: (ILI-st. 3 a- CorIFSE ) - ----- �.�OII:';'NunntY'r) f,)11 D2t:'_) I Mai a soli; propActOv, i'Cw I'_! xvirwor OF homcownCr �CiiG'.° O[1C1 ?I1G hot li?roi the comm ms lISted bdov tl.r- io!:: o:.:er comp ray.:: o, (�:amcof uNaIIIGOI cOi1Cr2CI[i.; LJi ,� L�_ Comy_..�/pGhC[ Nl!IDl-.r) rnIaIIIC 01 COr1t=dClon) t J (�`1atI1C of LOIItIlCI01) (Tfi,,.i�-ESC_ L_0?ll?n a'�OI�C1' 1`illiIl}�I�l _ •.[ c� (rWch,dhywu ?iOTI, ple-se nM rictc llL:n t}ucc t.r:!I ut«a.:d[L�r.. ., _.�;.:.^.,���. ,,.. _i, -._ ��..r;r;_•.rf Lx:dc cc n.:(�csp-r: �.c � - -- cn->Ie asua;`rt}rar.1-['�cn::---• ..•.na�rr`:;:L ...r ..... ,..cJ.. cg,l clam;of an-n{;loyx I uncle-zt—d d:.! f l}: y k_.o:rww�io.I to t:»i�-_tx.�tax-a:of i-1 Ac r, i CI!i,-of covansc vcrlCicaiioa a�itut L•ilurc t�r��::c v�`�ins;�r:r.-rcr xc:icn 25A of?.tGi,152 c Iced W t}x im;»;itiai :"r,'.:::i_-1 rxc_�!__ ONAaha of a fi r CUP to S103101 n lcr c::; .,_:'A up to c r}u e I cc[l xrullia in r f Rm cf., f r of Sl U�.CK? n dly 1,7a ia�t[:r Permit i tumtx:r SECTION 8 -CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : JA \SO v �' S C) License Number Ad ress Expiration Date Signature Telephone '.°M,6P c.UFew n. `^WC. H vt iF '# (9Ref�tered NomeImprbvemerit Contractor ;�,. Not Applicable ❑ pw Company Name Registration Number Address Expiration Date Telephone SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. 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...... ❑ 1�. Borne e a n 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 lie/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 Nvill be required from time to time, during and upon completion of the work fe-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 1,avvs 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 Zonni_ng� Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRII?TION OF.PROPOSED WORK(check'all apalicabl'e) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ / Or Doors ❑ Accessory Bldg. ❑ DemolitionU m14tr New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Wo u1 Gti � * ��� /�4�+t+_ r �t�nv (�c�! 1� [Tr;.At/,1t Alteration of existing bedroom Yes No Adding new bedroom Yes '` No Attached Narrative❑ Renovating unfinished basement Yes '-'--No Plans Attached Roll ❑ - Sheet❑ 6a" If Newhouse;ard or."atliiifion'"to":existing=Fiousin complete-th0"161'lowin : 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 a =;OWNER',AUTHORIZATION -TO BE COMPLETED'WHEN 01WNEkS"AGENT"OR'CONTRACTOR APPLIES FOR BUILDING PERMIT I, l�l,G6k Irre _, as Owner oft'ne subject property hereby authorize k1 �son _ _ to ac; on my behalf, in all matt rs 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. 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 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 parking) #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:_ of Northampton S, t, QI ding Department C. d 2 Main Street S Room 100 * a er N tha pton, MA 01060 aye s ,i ph X587- 240 Fax 413.587-1272 Plo it r,NSPE 0*fher�Specffj� APP Ln N TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This sectionfto be completed by office 1.1 Property Address: � �r„ _ = 3 (> 3 w A L!y tAT 5 l _ Map Lot Unit N 01J tt AM PTO AJ Zone � 'v+ Ojuerlay�Distrlct Elm St—District CB District SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: M IKE FoRar--S T 10 7 Name(Print) Current Mailing Address: Telephone ) Signature 7 Kai 5 2.2 Authorized Agent: M A S S U 13 46 Name(Print) Current Mailing Address: — Signature Telephone SECTION,3 - ESTIMATED CONSTRUCTION_COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by perm(Lapplicant 1. 15� acv Building (a) Building Permit Fee ----- , �I rival (b` stimated Total Cost of Construction from 6 3. Plumbing i Building Permit Fee 4 Mechanical (HVAC) - ------ — 5. Fire Protection 6. Total = (l + 2 + 3 + 4 + 5) Check Number This Section For Official Use Onl Building Permit Number: "/ ✓ Date Issued: — Signature: ------------------ - Building Commissioner/Inspector of Buildings Date File#BP-2004-0141 APPLICANT/CONTACT PERSON JAY WATSON ADDRESS/PHONE 24 SEVERANCE ST (413)625-9785 PROPERTY LOCATION 38 WALNUT ST MAP 25C PARCEL 217 001 ZONE URC THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out _ Fee Paid Typeof Construction: FRAME NEW C ILINGS PORCH REPAIR.REMOVE SHED New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included• Owner/Statement or License 079105 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFORMATION 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 Commission _�"-T o 3 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. h �h; BP-2004-0141 GIS#: _ COMMONWEALTH OF MASSACHUSETTS ` CITY OF NORTHAMPTON Lot: -001 Permit: Buildina Category: BUILDING PERMIT Permit# BP-2004-0141 Project# JS-2004-0217 Est.Cost: $15000.00 Fee:$75.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: JAY WATSON 079105 Lot Size(sa.ft.): 6272.64 Owner., FORREST MICHAEL&KATHERINE Zoning:URC Applicant. JAY WATSON AT. 38 WALNUT ST Applicant Address: Phone: Insurance: 24 SEVERANCE ST (413) 625-9785 SHELBURNE FALLSMA01370 ISSUED ON:817103 0:00:00 TO PERFORM THE FOLLOWING WORK.-FRAME NEW CEILINGS, PORCH REPAIR, REMOVE SHED 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 8/7/03 0:00:00 1585 $75.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo