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25C-237 pQ'KHAMP�O g ti� Cr itp of Xart4ainpton z Z � � �ilassRCl�asetts - s 1s. 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 has/her construction supc:-„'ssor. 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 ,l (i-zftT z�fIcYZ t12�t111}�fnlT 11 6 RliSSRC}J its CIta - ' L)EPIJu TMEN'T OI' £UIiDPl G INSPECTIONS 212 Alain Street ' Municipal Building NTorthampton, ATnss. 01060 WORKER'S COMTENSATION INSURANCE /IFFIDAV1-T (l i stirs°J ff;m itte^) ____-- v"Ith a principal place of busir,esslr,�sidcnc - �/ 2 d _ /V�� �/13'�►�► < 701, MA do 11CI-Cby Ccr-ufy% un,� the p%1i15 21Ila peil ItiCS Oi pc;r�lll-', illilt (7t./am an cnaplo)'ei, providing the follovvirlt •:orr:crs C0111pC!mIjon covcmllC 'Or 1n}' employees wo6drig on dies job: �l! 64ZT i Gf� �� � lv� ��3�� 171 PO)O l� � �Q ;0 n (Lns-=c-z Cora pain,) ;o c,?�'t�n i n F^ (- be (Fx1; r,ti_n Date) ( ) I ac7 a sole proprietor, general I-,- homco%-,�Cer (circle Oct) and 11a,-e hired the contractors listed h-,vc the `oll- � erg ape D•— . Mg ort� Cot:. neon es (I amc of Conumctor) (Ln--u-ncc Comp-,:'r,-!Polk{ NllnlL---r) iT?': .<.,70' D?tc) (Name of Contractor) (7.I1S� P.0 Com�z.IV�Pe!ic,' N=,b--r) zpim,:ion Date) (Name of Coatractor) Jllsumulce Coo acy/Polic✓ NuinI ,Zr) =.x;. r:do Datc) - (Name of Cont-actor) —- (Ins1 rand Cotnr :y!Policy Num;�r) or Date) I i1ST1 t. Ole 1)I'UpC1C:Ji 1'111 nilVC Il0 QI1C ..'0r�-!iir{ for -mc.. if Inn a homc all *:O"I'r;:plc�sc tc nu-a.rc that•\�:ilc 1'f.!iG:J\11YT3\\rJ C. 1 ti ir,- ::>^ti:llrlC�CL::_ i�Yl CS I:r. it a \c!!i c. not uxYe th n thrvo uzli%jr: au L' '_:rJ zr.,r cr_r1 LhCRO T n t EcYSall} c,_r:::( :o t� `:`P1 ucrdcr t}x tvo :^I'• � - _ p y c} _ar x :e!Irn,:r(Gi.152 1 Sl!.-:;'.,:_::tc:;by a hot•co,%-ncr:`cr a Lcc;c cc legal etatus of an amployor unur tL•o Wo i;elt l 02• m-anon:`.CL I ur>de.-ctand Ihi a copy of thin dais-st muy bo fau•nrcao;l to II»t?ctiertt C;uoo of coverage vcifictioo and th t L hurt to tL•c oo�cl g~ul u"iM 25A of?.SGL.152 stn it.-_d to the imrosition cf r ir_1 past:a comistmg of a rur_of up to S 1.500.00 a:t''nr i-nri r. ^1 of up to Cm.-)-,z-:e:-.l civil xnx1GCz in dC Cann of n S!�.,`:'ni_Ch1=a:.:1 a frlr oCS100.00 i diy qp.ina m:. �•,^,� - For dq:ut:xrrtsl``ly i perrnit Nutntr.:r --_-- ct— ---- - :i':�I 1 5l nattlrC of 1.iccCrJI) :IG: r - I F MN r " S C N ON� 7 � "IaiSTR-UGT10„ SERVICES u 8.1 Licensed ConstructionSru'pervisor: Not Applicable ❑ Name of License Holder : og;2— )dy L License Number Address (` Expiration Date Signature Telephone 6}�,��'�OD �J Rees rra: . =m u: rnen. 0 n r.�a:c o _' Not Applicable ❑ Company Name Registration ymber Address V Expiration Date Telephone gx SECT A O�RKERS' COLVIPENSATION--1N,SURANCE:AFFIDAVIT(M.G L .c. 152, §,25Q, 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 he 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)famiLes 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 and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SE4Tu S( tffl[ �ROPOSEDWWORK ctiecW71 I�t�a'tile New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Rt- o g ❑ 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 D Renovating unfinished basement Yes No Plans Attached Roll 0• Sheet 0 a a a zt o a atron to is i n ME-6.o;m'" ow;nom: 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 E ( W E `UTORIZAT}ION TO BE COMP,L3ETED WHEN 0 E SAA OITRACTORAPPt.IES FO:R`BUILDING PERMIT h , as Owner of the subject property hereby authorize to act. oi my behalf, in a matters relative to work authorized by thig building permit application. c/ I C -a✓L .2 1 C C�J Signature of Owner Date I. 2-4� w'A) as Aw r/.Authorized Agent hereby declare that the statements an 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. Pri Name try , Signature of.Q, a/Agent Date t , 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: S. _ of Northampton �`g l u ing Department 2 Main Street Room 100 No ha pton, MA 01060 phone 587. 240 Fax 413-587-1272 F QF�111�p1NG INSPECT��S nQ ;, - TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORIYIATION n This" ectao om ► fic` �� ,_ 1.1 Property Address: ,��//G x ✓i` �4 A !-y1 /Q� v , Eim t D"t'strict �$, isct :� SECT4ON"2- PROPERTY°OWNERSHIP/AUTHORIZED^A,GENT 2.1 Owner of Record: I ids m dA �AM0 0✓ Nam (Print) Curren ai181 ,d ress: rn J A�0 n�7��_rn_ -�res ✓�- A`V'11-- Telephone �40-1 �a Signature 2.2 Authorized Agent: ,/ Name(Print) Current Mailing Address: Signature Telephone SECT ONF3' ESTIMATED CONSTR CT"IDN COST Item Estimated Cost (Dollars) to be Official Use°`Only completed by ermit applicant 1. Building ©p (a) Building Permit Fee Al %O 4 2. Electrical ,^ (b) :-:atimated Total-Cost of Construction from .l5 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total =0 + 2 + 3 + Check Number This Section For Official Use:Only Building=Permit Number> Date Issued: , 5igna#ure: Building,Commissioner%Inspector of Buildings.,:. Date.: r r i l ST BP-2004-0216 G1S#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2004-0216 Project# JS-2004-0315 Est.Cost: $11000.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: B & R Siding 100465 Lot Size(sa.ft.): 8799.12 Owner: RAMOS ESMERALDA Zoning.URB Applicant: B & R Siding AT. 201 BRIDGE ST Applicant Address: Phone: Insurance: 781 Bridge Rd (413) 586-4167 Workers Compensation NORTHAMPTONMA01060 ISSUED ON:8125103 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING 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 OccuQang Signature: FeeType• Receipt No: Date Paid: Check No: Amount: Building 8/25/03 0:00:00 18898 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo