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25C-242 (2) �Q'ZHAMPIO ,r ' Crzty of Wart4antptan z s $ � �LTassxchusctfa - DEPARTMENT OF BUILDING 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 780CMR 108.3.4 to act as iris/her construction supc�, ,• sor. T he 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 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 M,—1 Address of work location 'tz t �G E (5i'13 eF_i y` I (1IlhT Of Ni1.7).rtf}c1111ploll � 6 fi�RSaacltnsrtle' I D@PAR1'I,,,EIJT OF LUILDDJ G INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORKER'S COMI'ENSA'nON INSURANCE AFFIDAVIT (1 i ctins^�rrr u1 i t iC^) principal place of business/reSidcnce �strceU'ci .jp) do lleic,)y CerL11-v_ t!11C' I Llle t)a ills ::ii7 pC i1 l !e- �i pc;f�111�1, :Ili!:. O I am an employer providing the 1,0110%,"Int •.<)rr_ers COIl]pCnsation cover C or 111y elrlployees worldrig on t?1is job: (IlLn>rana Cocypsm') c cr Nunl>cr) ---- (F}. .irr tion Date) ( ) I awl a sole proprietor, general contiac-cr hoaleowce: (cycle onej and tla,:e hi td thic CORtTaGtOCS listed bCiQvi ill iQJ " v;o kP,-2S commtnst ion -O!iC:Cs: (Name of Contmctor) NwnLYr) (L>::irr:aen Datc) (Namt of CoLn=,or) — 1711SJ P-C { C�1D i�'/�G!tct' \ I it/f) (�:`:v'::'ailOC Date) 0""ame of Contractor) Jnsl:ranc Com, np/i'olic: Nu1i)txr) =s,.s doo 1:-aie) - (Name of Contractor) — (Ias1 ruic^Color ,)lPolicy Nu.mlr2-*) l 1 11111 a 'sole proprle:C)i Z1,"J }I iVC 110 one f0+ nle,. ?ill <? home ev1�e- NO"rT:plc-sc Lac a:.->.;c tls;xi•i}c txcrc:���:r_ra.��c r,�l:-; i}—.=�:n:q::�::,t:�anc�cz._::n:cv'm cr:rpau�� ,....._d.�cilir:�c. not utoce th_n throo uni+s i:,%,i--d•hc or oo I. U.::s zo•_r cn r1 LF :o c rr_{�S-tally a :`:.'!:;':c t` cniploycs ur.'. t}tr-tvc;l:f:cGrx-=:--:::i-n x (5) ,a+: ._a:icn by a ho:a o:: `cr a Gcc c cc p-ra:i::: rtic legzl clams of as oaxployec unu' tiao Wo kc1t !.cf- I undc-:Ixnd Iha:x copy of th:i cIatc.:s=rv.y bo Corxnrciod to II»IY.Siortzwi:of lydus:tinl M�I,a:.�Clio°oC i:::+_+c��for t1x covcn&-e vcriGC:,iioo and that failure to!-c-r- 25A of?.(C-L,152 can Imd to the ir"P-ifiol of cr-viral[cr'zl;:= comisty g of a fu)"of up to S 1.500.00 n;t1'c< of,!,to cr.:)- t:,j civil,>cm)tic3 in to fi, 1 c•( Lrz,of S l 00.00 a day i paina m- - _ ror&gw1Tm tat u>•e cr:ty - -- Sl-naturc()f;.ic�u rJ1'crmi,tr; ! S€CTON 8� CONS# RUCfIQN SERVICES R 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone egs a bt7a .mpg ,.e: "en. . on'#racEo Not Applicable ❑ Company Name Registration Number Address Expiration Date Telephone SECTI4, 10 WO �E RS' MPENSATION NSUNCEAR FFIDAVIT(M ML-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...... ❑. 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 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 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 and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature i - I ^ I I � to SECT,o�±15D�5C�2fPT�lOiJ `F�PROPOSED��IIORK cMeckall New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition[] New Signs [ ] Decks [ ) Siding[[ ] Other [ ] Brief 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 o. Sheet❑ 6a,_ ` ems_ o _: a""�d.ition�:to ez=istingh�.ngg�c�om=p� �h"e�llowrn� 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 regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply 'SEC�'C,�OT( ���WI-ifER��U���HO�RIZATfON TO BE COMPLETED WHEN OW.NfF�SE CONTRACTOR APFLhES, FOR BUILDING PERM'1T as Owner of the subject property hereby authorize � � i i to ac:. or 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. 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 St Fronta e 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 V 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.IMain Street ~= Room 100 Nor'tharnpton, MA 01060 OCT phpn ,613•587-1240 Fax 413.587.1272 w � p k . *LIG94T M TrQ.t34RUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING ........... SECTION 1!- SITE INFORMATION This sect�o Ito b° omp'etedy office 1.1 Property Address: � e I—� y a`✓.,SjA �A�`� .^°` JML�fi�'4he fz4•. 917 � S I rzec � JVIaP a0 1M � �ItL a/06 06 0Zon D� #r ct k k Elm St District' GCB As rich r SECTION 2 PROPERTY- -'OWNER! H F AUTHO:RIZED:AGENT 2.1 Owner of Record: Name(Print) n Current Mailing Address: I", C, � Telephone Signature I.Y 1 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone S.ECTON..3.-ESTIMATED CONSTRUCTION COSTS` Item Estimated Cost(Dollars) to be Official Use' 1nly 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 Bi�ildi'ng Pejmit-Number. Date Issued: Skgnatu re: 1 Building Commissioner(Inspector of Buildings Date T 219 BRMGF,St r BP-2004-0525 GIS#: COMMONWEALTH OF MASSACHUSETTS l i�iii:131ock:25C-242 ' CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: BUILDING PERMIT Permit# BP-2004-0525 Project# JS-2004-0742 Est.Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin Homeowner as Contractor Lot Size(sg. ft.): 7187.40 Owner: SMITH HELEN C Zoning:URB Applicant: SMITH HELEN C AT: 239 BRIDGE ST Applicant Address: Phone: Insurance: 239 BRIDGE ST (413) 586-7894 () NORTHAMPTON MAO 1060 ISSUED ON.10130103 0:00:00 TO PERFORM THE FOLLOWING WORK:INSTALL WOOD PELLET STOVE 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 Sisnature• FeeType• Receipt No: Date Paid: Check No: Amount: Building 10/30/03 0:00:00 Mo $25.00 212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272 Building Commissioner-Anthony Patillo 239 BRIDGE ST BP-2004-0525 GIS#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25C-242 CITY OF NORTHAMPTON Lot: -001 Permit: Buiidina Category BUILDING PERMIT Permit# BP-2004-0525 Project# JS-2004-0742 Est. Cost: Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sg.ft.): 7187.40 Owner: SMITH HELEN C Zoning:URB Applicant. SM]THHFL N C AT. 239 BRIDGE ST Applicant Address: Phone: Insurance: 239 BRIDGE ST (413) 586-7V4-Q NORTHAMPTONMA01060 ISSUED ON:10130103 0:00:00 TO PERFORM THE FOLLOWING WORK.INSTALL WOOD PELLET STOVE 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: 1-7 3 THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT N OF ANY OF ITS RULES AND REGULATIONS. pe Certificate of Occu anc Si nature_: FeeType: Receipt No: Date Paid: Check No: Amount: Building 10/30/03 0:00:00 MO $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo