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17C-103 (2)
..GGtu of Wart4amptan z __ r �'d eSSAC}�IiSCffs - DEPARTMENT OF BUILDING INSPECTIONS / INSPECTOR '212 Main Street • Municipal Building ' i�,y Ste.♦� Northampton,MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her construction super .,• :;or. The state defines "Homeowner" as, "Person(s) who owns a parcel on which he/she resides or intends to be, a one or tivofai ---_._ 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." TheeUuil mg 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 fegulations. 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 1 �,Tcrf1113111ytoil - R � E g1s�aRChntrlls' r� DEPARTMENT OP BUILDf\'G INSPPCTIOI.'S 212 Alain Strcct ASunicipal Building Northampton, Macs. 01060 I _ WORJaR'S COi!fPENSATIO.N G SURA2hCE Al' ,� VIT — r _ rrt 4p je .. .-..-- -- I pic�nsxJperirvticc) %vim z principal place of business/residence at: -- c�333 �fu ���r I��, �it, - c� [07 3 (phone') 5 (==Uci tyls=12j p) jdo hereby certifjr, under ttic paint and penalties of perjury, �c1I — i ( ) I a_rn an employer providing ilie following!.:,orkcr's comocasaio covervge for lily etuplovecs wor:ong on tills job: Cocz v) (Polio: Nt��ixr) _ :'pir`tion Dz c) ( ) I am a sole propf;ctor, general conrracor or homeowner (tide one) and have hired the contractors listed below wbo }lave the `otlo,ving worker's COmpen_s26on pokles: i i (N amc Oi Co'2'_^ciGr) (Ins r rlcC: Comp1nypt ouci (ExpI JOon Datc) (Nme of Couu aor) (Ins-,L-an= ComvaativPo!icti• Numb-=r) (-Expr6on Date) (Name of Co=-aMof) (Insurance Comp.aryfpobcy Namtu) CExpim6os Daic) (Namc of Conawior) (Irsuraa<—_ Compazy/Policy Nun2yzx) i---piraiian Dalz). (ntssGtt�i�o�J dca.ifaccr- _-ti•w c�c?u�iaforma�oa pcLCiaia.�w.!7 cv�-s�o:-s) _.._. "_.. i ( I.am-a sole proprietor and have no one wor'dng for me. ( } I am..a home owner performing all the work myscT NOTE:pl=.=be awzm Lj, j o c=picy pe-.aas to d:)c+Cis— a, tas.:.e,,,o c r p.-ir-ark as.d,,r1 -Z of 1 Cat @OC-t SI:a L-'-0==' "to t'.bcb lb'bQCDOO+' =r73aa OC cc Lb'--PM'06 17pLr(GA_.=tbC.La't OC C('^—+•:�tIY CL--_e—cd la tY ertployc ua=Lhe..ui cu --*oa Aa(GL152=1(5)),=pPU=.7aa by n bomcowva f=clip.or lczaa r=-y c-idcD=cL- 1cP.I ct.=of sa-==loyar uodar d-Wockc<-.Cocxpematioa Act j I I t:adc•ca-od dad a Dopy of tbi.mt®Cis m..y be to the D q.,a w Acedaa, Offof lsaur+om for tbc cove- -c%"aZclioa sad th:t L-irtaz to s=rc tovc-rzc uodc soc60a 25 A of MOL 152 csa 1--d to th4 i^xsitioa cf cimias!pcmxltia corm:i.xg ora riot orup to s }oo.00 cn3ror impriyoa,=c=orup to oat yr=r tad Civil pcaal-ia is d�form of s Stop Work Ord--nod. rim or S 100.00 t day tpdc:a cy-- For dc'-,a only i par'ni7t Numb= Lot R sig ate of Licroscr- cm-iu e j SECTION 8-CONSTRUCTION SERVICES t 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: O / i lSt d t�r`Pl y 9( License Number S-� , Addres Expiration Date z Signature Telephone Re -s'iee ,_o e nraco° Not Applicable ❑mv Company Name � Registration Num er --— - -- t L. �A" [. 5 f �o�% .v Qr�7 6-a5 -o Address Expiration Date Telephone Sd?-03.3 3 SECTION 10-WORKERS'COMPENSATION,INSURANCE AFFIDAVIT(M.G.L.c.1 62,§25C(fi)) 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 buildi permit. Signed Affidavit Attached Yes....... No...... ❑ it 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-vear 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 Deai.1-i)of use 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 r SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Wigdd"ws Alteration(s) Roofing Or Doors 10' t Accessory Bldg. ❑ Demolition New Signs (tom] Decks [M Siding[0] Other[E] Brief Descy. bon of Proposed j ( ( Work: P ��Q�� 1 ro.�: 4 S Pt?^ �� : 1'tQc o O►1�e � � 1-(nv.- ( . Alteration of existing bedroom Yes No Adding new bedroom Yes No'. Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet C �an`*� *a 9�,-•:„ -y . Est-<Y'. '"""°"�,.- .. �"� 7'�s:fix';': s..'.sr._^9; ,^,�'�- 'r. sa°lf-Me 'Muse-an c�a��d►�io��a��us inc� aa�s�ng�cor�p�ete�he�ioyrii�g 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 7a-OWNER AUTHORIZATION-TO BE COMPLETED;, HEN OWNERS AGENTOR CONTRACTOR APPLIES FOR BUILDING.,PERMIT as Owner of the subject property hereby authorize to act on a If,in all matters relative to work authorized by this building permit application. Sign ure of Owner Date ---------- 1, rv^t V as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my now a ge an3lelief. Signed Q,n LQ"A a 0"under the pains and penalties of perjury. ' k,ED Print Na Signature of Owner/Agent Date Section 4. ZONING All Informatjbh 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 Rear Building Height Bldg.Square Footage Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces ' A. Has a| Perm it/Vuhance/Finding ever been �suedfor/on the she? ' x�� DON7 �NOVV x���� YES »���� � K� �� IF YES, date issued:! IF YES: Was the permit recorded at the Registry of Deeds? NO v���� uu" / "=O"" U .^" lij IF YES: enter Bonk Page, and/or Document#: B. Does the site contain o brook, body of water nrwetlands? NO ��� DON7KNOVV v_� YES IF YES, has permit been or need to bu obtained from the Conservation Commission? ' Needs tobeobtm[ned Dbtmiomd ��` Oa�a |ssue��' | �^� ' C. Do any signs exist on the proporty �� ��� YES �~� NO v�� IF YES, describe size, type and location: 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 grading,excavation,nr filling)over 1 acre nrisd part nfo common plan that will disturb over 1acre? YEGK~_°) NO �`~�) / IF YES,then a Northampton Storm Water Management Permit from the DPW is required. §► Departmenti use only City of NortF ampton aatu � � * � �7 Department Building b�Cp ae 212 Main Street Room 100 Ndrthampton; MA 01060 j JUN - 4 ;9§ne 4587-1240 Fax 413-587-1272 k I{ D "'`0#Ja'4p ON j*o!!TR CT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION This sectron to be com�Ieted by office � ° " 1.1 Property Address: ii s t t ' ��d•v Ave ZoneOayUistrict Elm-St.Distract CB Aistnct SECTION 2--PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: —7 r i / T 1 1�c)CJ vtl ^L ��I"e12_ILsL r` `It- 0,0 Name(Print) Current Mailing Address: 96 o Telephone Signature 2.2 Authorized Agent: d � ��� ✓ !Co �c��i cC �v �o yln73 Name(Pri n 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,Permit Fee 2. Electrical (b}Estimated Total Cost of Construction from 6" 3. Plumbing Building Permit Fee 4. Mechanical(ri V AC) 5. Fire Protection 4 PAN*a Z510 6. Total=(1 +2+3+4+5) Check Number This Section For Official`Use Only Date Building Permit Number: Issued: Signature: i Building Commissioner/inspector of Buildings Date File#BP-2008-1087 APPLICANT/CONTACT PERSON ROBERT CARRIER JR ADDRESS/PHONE 16 David St SOUTHAMPTON (413)527-0333 PROPERTY LOCATION 17 STILSON AVE MAP 17C PARCEL 103 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Buildiny,Permit Filled out Fee Paid Typeof Construction: REPLACE FRONT&SIDE PORCH DECKING&ONE 2ND FLR REPLACEMENT WINDOW New Construction Non Structural interior renovations Addition to Existing Accessory Structure - Building Plans Included• Owner/Statement or License 059154 3 sets of Plans/Plot Plan THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF ATION 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 Permit DPW Storm Water Management Demolition Delay 200 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. BP-2008-1087 17 STILSON AVE COMMONWEALTH OF MASSACHUSETTS GIs#: CITY OF NORTHAMPTON Map:Block: 17C- 103 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Lot::Blo Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A) BUILDING PERMIT Category: Permit# BP-2008-1087 Project# JS-2008-001607 Est Cost: $7670.00 Fee: $50.00 PERMISSION IS HEREBY GRANTED TO: Contractor: License: Const.Class: ROBERT CARRIER JR 059154 Use Group: Lot Size(sq. ft): 9888.12 Appl cant: ROBERT�CARRIER JR Zoning: URB i! C .! AVE AT:T� i t DTI.__ - Phone: Insurance: Applicant Address: (413) 527-0333 16 David St SOUTHAMPTONMA01073 ISSUED N.- 12008 0.00.00 TO PERFORM THE FOLLOWING WORK.-REPLACE FRONT & SIDE PORCH DECKING & ONE 2ND FLR REPLACEMENT WINDOW POST THIS CARD SO IT IS VISIBLE FROM THE STREET Building Inspector Inspector of Plumbing Inspector of Wiring D.P.W. Underground: Service: Aleter: 4L.G'S a }� Footings: Rough: Rough: House# Foundation: G"! 7 O� Rou g Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace/Chimney: Insulation: Rough: Oil: Final:©'�' Final: Smoke: THIS PERMIT MAY BE REVOKED BY H TY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGU N Certificate of Occu anc Si nature: Feel e: Date Amount: Building 6/4/2008 0:00:00 $50.002474 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo