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17A-042 (3) Q�1�MPT C�ii# of Xort4auipton Z Aimach Its rtts �t V 5"1 « DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street @ Municipal Building ' Northampton, MA 01060 a HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as iris/her construction sup : • -,or. The stave defines "Homeowner" as, " Ierson(s) who owns a parcel on which he/she resides or intends to be, a one or trvo family dfvelling, 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/footinp-s (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 wn /resi nt'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 � 6 ��i1E AC11(tECIIE _,� P, DEPART}.PENT OF EtUILDP�G INSPECTIONS 212 Main Street ' MunKIA ,,Irr3��VAInf, Northampton, AWT OIM10 A WORKER'S COMPENSATION INSURANCE AFFI-DAWl' 1, - (�ICCnS; Nvith a principal place, of businesslresidence <,t: do hemby uoai , Hide, the O!ili1S and OC naltlCS of pP.flllly i..... I aiii 2n etnployei providing the following =Ws compansflIun coveiQ.!e for my employees woil. Ilv oil this job: - - --- ----------------------- (Incu -anc;. (Polio;Number) - (E�:pir.:i on Date) ( j I art a sole proprietor, ;general contractor or ha eonmer (circle onu) mi(d have hired the contractors listed bdov who have the fo[Ic,-.;_] woCe,ejS COi??i) rS<_:io i)Cl]C:eS: —(Nnnle of convamor) Osman= Coinp.:::r,'PM&y N nnrW (1=Mr:nv;We)- (Nmnc of t -JP. aczor)l (j,LSUrancc CoII.:;m.y/Pt k! ,, (Name of Contractor) (Insurance Com,;: �yii ol.ey Ntur.l.�r) z,. bate) (Name of Contractor) (Insurance Coui,at;y/Policy Numt'ir) 1 :ri uo:;Date) i ) �>1n a sole t;rc�p:ie:cir ziid have no one .�,�;!hil� for ( , l ?ill a Moline o%v'),C: !)CTf inning all Lie �'IOrr; iil`rsClt_ JO I fi:plc-sc l�n rare ths: .ti}:ilc f,un o ti;r_n rti;�c:play i=: to ;i-,-,-_cane, ci:.ct:a:,Yt r::::,;a r• ";j,:-- i«c:!i:: cc( not urccc then tluro t:ui±t is wi�:c.'t•fix hrti�u;-rr rnt%w cc oa t:u�_�.:�,^_�:���trtc;�'Lic:do r.:c:n<f;crr�l!;o��.;:dr:::':�h cmploycl urx:cr th two ci m.:�.--_uticn Ad(GL152,_-31(5)), '~n,7c 1-' UPI A.Wx of to Myhyo(-uncle ti:o Conr;xrnation Act_. I undmnmd On x copy of th:j c1atc--i may bo fcnx nniod to L!]Depart.-,—I of Irxuutn al Aa�1 mti Ofli—of I:--o for tltc covaagc Vail calioo and that failure to s—Luc covcrtE�c under:cdicn 25A of MG1,152 cw lc:.d to tix PMARS C&MAIina of a t r_Cup to S 1 50TC. o a:�'or of up to con)w nni civil ynA iu in Q Awm a-Stc;t W"k COW awl a firm o(SI�.X)E�}'ignlm.t ar_ Fir da; n" [ 02 'crrnit Numtxa _-_-- - ' Jtm ttur of f.ic n� JI'crnt arc SECTION.&-FCO,NSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number r Address Expiration Date Signature Telephone , .. ,._ 'a Not Applicable ❑ 9 Reds er" e rfom m—Me—F ent�.Contractor: . . .r .. PP 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...... ❑ IN 0: ®4W 11� :emiarr 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 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. xHomeowner Signature l SECTION 5 DESCRIPTIONtOF PROPOSEI)WORK(check all applicable) .., �.., New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolitio New Signs [ ] Decks [ ] Siding[ ] Other [ ] Brief Description of Proposed Work: l� — l�� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative❑ Renovating unfinished basement Yes No Plans Attached Roll ❑ - Sheet❑ 6a IfNewhouse a"ndoradiition4_fo_.existmgaiousin ,,comp1ete"the4 6 11 owin : 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 7a OWNER AUTHORIZATION'-TO BE COMPLETED WHEN OwNERS'AGENT OR CONTRACTOR,APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize to act on 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 N � ` GY rnct ;� A � Signature of Owner/Agent Date <j — U3 . . . ~ ~ ^ 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 Rear Building Height Bldg. Square Footage % Open Space Footage % (Lot area minus bldg&paved ffi Sp #of Parkin �6s (volume&Location) " A. Has Special Pernoit/Vahnncn/Finding ever been issued for/on the site? NO DON'T KN0W 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 Pa8e and/or Docurnent # B. Ones 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 tobo obtained Obtained . Date Issued: C. On any signs exist on the property? YES NO IF YES, describe sizn, typo and location: D. Are there any proposed changes to or additions of signs intended for the property ?YES No ____ |FfES, dau6ribeoizo. type and location: City of Northampton S tits der Building Department Ct r a MAY 2 1 212 Main Street Se er Se I Room 100 a �r 1Ne V 4_ Northampton, MA 01060 ph6ne 413 587 140 Fax 413-587-1272 P�1o�fte, an Otier�Spect APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION-1 -SITE INFORMATION Thissection tobe completed by office 1.1 Property Address: g p( d /�Q Ma Lot a� � Urnt 151 Q Ca Ad Zone, Overla District Elm St. District CB°District' SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: Narne(Print) Current Mailing Address: _ t Telephone Signatux � `7 --- 2.2 Authorized Agent: 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 r (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 Building Permit Number: d Date issued: wv Signature: _ Building Commissioner/Inspector of Buildings Date File#BP-2003-1053 APPLICANT/CONTACT PERSON MEEHAN JAMES A&HARRIET H& ADDRESS/PHONE 192 BRIDGE RD �lL` —�5--d PROPERTY LOCATION 192 BRIDGE RD MAP 17A PARCEL 042 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid c � T_ypeof Construction: DEMO SHED 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.WKATION 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 Commis 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 BP-2003-1053 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2003-1053 Project# JS-2003-1676 Est. Cost: $0.00 Fee: $10.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq.ft.): 14984.64 Owner: MEEHAN JAMES A&HARRIET H& Zoning.URA Applicant: MEEHAN JAMES A & HARRIET H & AT: 192 BRIDGE RD Applicant Address: Phone: Insurance: 192 BRIDGE RD (413) 584-5250 0 FLORENCEMA01062 ISSUED ON:5129103 0:00:00 TO PERFORM THE FOLLOWING WORK.-DEMO 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 5/29/03 0:00:00 5019 $10.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo