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12C-068 (6)
-- o � I � �1 � -r - - � � � i� _. �� ��i � i "' �_ _l -- ----� ¢'tHAMP�. r O O LEI zfg of Xar#4alitp#ian I1 a ,51_3__."t..__,.. DEPARTMENT OF BUILDING INSPEC'T'IONS 212 Main Street • Municipal Building INSPECTOR .. 5 `' Nort ,unpton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act aS ;.is/her construction sup'.: •- .or. The state defines "Homeowner" as, " Person(s) who owns a parcel on which he/she resides or intends to be, a one or two fahuly 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/footin s before backfill sonotube holes (before pour) a rough building inspection(before work is concealed) insulation inspection (if required) and a final buildinz 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/ eside 's i mature rg questing exemption) I will call to sch ule all quired buildi in spections necessary for the building permit issued to Date Address of work location V V i A `b �LIf�7 LTA �\Tc iIja11lptoll — A J H �7csanrflnst(!a' _ 4 OEPARTMENrT OP ©UfLDf?\:C INSPECTIONS _ 212 Main Street Municipal Duitding Northamplon, Mass. 01060 %N-'OR=-R'S CONTENSATION MSURANCE AFFMAVIT (li craS�Jperm�ttcc) %kflLb a prulcipal place of buS1L]e5s/rcSidc'I]ce at: none (Sa=uci tylsutc/n P) do hereby cerdf}r, under dic pz_ins and penalties of penury:, Ihai ( ) I am an employer providing the following worker's coinocnsZzion cove^ge for (ily eluployecs woflkang on Crtis job: (LrLnu-:�� Conr�.r7') (Petic; l�u.�.bcr) �:�pirrior, Dzse) ( ) I am a sole proprietor, general coacractor or homeowner (c cie one) a.nd have hired the coati actors lister+ below who have the ;'okw�og worker's comoenuhon Po'licies'. (i+aIDe ai Co tretor) (insuranc: Cornpamyi oUCi ���uIIlL<�) -- (I"_•`-JlrJl?01 D.11c) (Name o[Coacraclar) (Lnsaraacc C-omoanwPotic Date) (Name of Coa[aC-JOT) (Instcranc Comlzan)-/PoUq- Nusb,--tl (Expiabao Date) (l'`ame of Contractor) (Insurdncc- Comcaaylpolicy Number) (Expiraiioo Dar). (siI1[:1 �oca1 dcC.ilncec --Y to as�v<ic inform.;oa peruuni to.0 O.C=-1'-on) r. Y { ) I am a sole proprietor and bave no one worming for me. I am,a home owner perform=ing all the work myself. NOTE:plr_sc be a.-,xt r+,,.wf 7c 6omxMVCn rbo czz�lay pcwca to si c�coo ar m,as w-orz on.d.•�'t:^�of nae azecc th:.a tl:ro--j is ,inch the bom�rtida of oa the ffounc_i a77:utco_r1 tbee: ox C=n,.lty a-=d.--od eitploye.un c the--k=;ca=pa-. oa Aa(GLt 5?s 1(5)).=vU=6ca{ry a 6omeoavc fv_l ese a permit r=y c-rd=D-the {e�c'taau of ea aaployx aod. dsn\-V c. ,Coa ioo Act I u.odaa..nd d i copy of thi. —y ba fog-�.a�dr!to tbo Qcq�rtmwt aCiuv+s+i..l Acodcz�.�OT—or(r..---rot'b- eo—&,c-=i c=110a Am e!u L-..i)=to soevoe 23A of htoL 152 can Id to the i=po li60a of ei�peuiltics oo¢zi�of a rsae of up to S I SQ0.00:r Icc�isorn�of up W ooc L d c.il P.._Rjo in be form of.Slop W or{;Or,6 -and a C=of S 100.00\d_y.pyast me Far dcp.rtm�"�`r•c only - . C Pcraa i Numb= )`lap° siUp.aturc Of Lic=ascrjpccrrtittcc A SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone �:ReUistereii 1 CoiniCniproveinentContractoi - Fx� p41 a Not Applicable ❑ 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...... ❑ 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:Per-son-(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 SECTION 5-DESCRIPTION-OF PROPOSED.WORK,(check_all,applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors t kM Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Sid' g Other[0] Brief Description of Proposed ` ^ f ENOV I Work: 1 v 1hS ll `". �I } i l�G FiN Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet -,- .;°Nt^ sa l lVev(r[�ouse:anc oradditG'4 toexcsf>ung;.ioust�tg c"omptet Fre: itiovr�mc: 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. Masscheck 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:7aF-OWNER AUTHORIZATION TOc BE COMPLET-ED WHEN OWNERS.AGENTORCONT.FACTOR€APPLIES,FORBUILDING PERMR r as Owner of the subject property hereby authorize to act on my behalf, in all afters relative to work authorized by this building permit application. Signature of Owner Date I, S 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 + <S k, VJ Signature of Owner/Agent Date ^ * ~ � ' Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning T'his column to be filled in by Building Department Lot Size Frontage Setbacks Front Rear Building Height Bldg.Square Footage % Open Space Footage % (Lot area minus bidg&paved #of Parking Spaces (volume&Location) A. Has a Special Perm it/Vurance/F been issued for/on the site? NO 0 DON'T KNOW YES 0 |F YES, date issued: IF YES: Was the permit recorded at the Registry ofDeeds? NO � } D ~~� IF YES: enter Book Page; � and/or Document# B. Does the site contain abrook, body of water orwetlands? NO e DON'T KNOW 0 YES 0 IF YES, has a permit been or need tu be obtained from the Conservation Commission? Needs to be obtained �~� Obtainmd �~\ Date �~� �_� ' . C. Du any signs exist on the proport ��y? YES \�/ NO «~�/ IF YES, describe size, type and location: i D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre orisit part ofa common plan that will disturb over 1 acre? YEO [ ) NO 1/(} �� _�� IF YES,then a Northampton Storm Water Management Permit from the DPW is required. w f Depar�ertise:only� �-�� City of Northampton Status�oE'ermtt x Ri i jriinn npnartment c irf i Er7ri�P rye 4 212 Main Street SeGVekl�eptc��� ? Rd,Om 100 IaferteClvailCcFif� x ' Northampton, MA 01060 Fov iio zairu ctura .x xa y3 i phone 413=58 7-1240 Fax 413-587-1272 Rtat APPLICATION TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION'1 -SITE`INFORMATION 1.1 Property Address: This section to be;completed by office MA 01 v v 0 Zone Overlay District Elfin Sta oistr►ct CISiRistrtct SECTION.2,-PROPERTY OWNERSHIPfAUTi iORIZED AGENT'' 2.1 Owner of Record: x '�► N u L S� F10Ke116C , MA 0/v&it Name(Print) Current Mailing Address: 7ti1,6'—fi L03 515 , Telephone I'S? � Signature 2.2 Authorized Accent: 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 (a)Building:PermitFee nC 2. Electrical (b}-Estimated,Total Cost of � Q Construction from:;6 � 3. Plumbing t„ ,,,1 Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total=0 +2+3+4+5) 0<Y0 Check Number CJ This Section For Officia[Use Only Date Building Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2007-0402 APPLICANT/CONTACT PERSON COX SARA ADDRESS/PHONE 31 HAROLD ST FLORENCE (413)585-1572 O PROPERTY LOCATION 31 HAROLD ST MAP 12C PARCEL 068 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildin Permit Filled out L ttli Fee Paid Typeof Construction: INSTALL SLIDING DOORI&SIDING 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 INFO ATION PRESENTED: pproved 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 Co on Signature of Bur ding 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. R 31 HAROLD ST BP-2007-0402 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-.Block: 12C-068 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-2007-0402 Project# JS-2007-000590 Est. Cost: $2500.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 12196.80 Owner: COX SARA Zoning: URA Applicant: COX SARA AT. 31 HAROLD ST Applicant Address: Phone: Insurance: 31 413 L RENCEMA01062 ISSUED ON.10/11/2006 TO PERFORM THE FOLLOWING WORK.-INSTALL SLIDING DOOR, DOOR , REPLACEMENT WINDOWS & SIDING, RENf) 1<l TGN>5,J 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• Date Paid: Amount: Building 10/11/2006 0:00:00 $50.003087 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo