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17A-264 I� i C L�° op s- 4 �tKAA1P�. Grify of Wort4ainp tan M r �ASSAChItBttfA {s DEPARTMENT OF BUILDIT?G 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 };is/her construction sups: sor. 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 LAY the project until such time as the proper permits and inspections are made 3 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 • 4�tV.Hl�TU "".� _ -of '�Narfljuiwptoil $ 6 i�i5eachnscI15 — DEPARTMENT of £t1ILDrJ�G wspLcT1oNs 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORICER'S CONITENSATION INSURANCE AI+FD)AV1.T v"1111 a principal place of business./res dcncc (ph ne.' - CI0 hcrCby CCIi1Iy, Ln:' !" Lhc p<:171S 3i1i pel i"1Cs of nC:fJUry, tlli!t: O I am an employer- providing the ollo,.,r:t_ ..orr,crs compcnsauofl covert e or :ny employees working on Lhis job: (Insuancz Company) i e'�c,Number) ---- (E.xpir:don Date) ( j I ant a sole proprietor, general C-on I-l�C70F o- non eo Me: (C', 'p, one) and 't�:ave hired the contractors listed beior� ,��1}o f:� the fol���.:�:;, o; ers compen5�_ on policies: (_Na c of Co!1tmctor) (�Ll_L''i'.DC:, I.GIL!�:::i'j:�Gl1C"{ NllSTl i) ,rx: .c.:!c-Datc) (Name of Contr:c,,0r) tTTIS-j .;nee Date) (irtame of Coatraclor) (lIl 'J 7I1C t_o :'il;i/I�OIi�: w11JLli.7) S;.S i]v Date) (Name of Cane ctor) — (Ta, ane:. Com,_:.),Policy Nu.mbir) i-_:_:.':t:�'.. l I �LTl a sole prOl?nf tC?i" <'.i1Q 11?vc 110 ollC '.','U?k1n for mc. 3i11 2 11011 1C OVV?lC- NOTE:plc-sc be nw. :c 1113;a ;}=tx•-�:� 1r-5 t+:o c: �1 ;r.. -_ �� 1:�ncc cY..:_n c m cr:-,:a r. «cl?:- =. not UK)rc th-u d rco unite in tti idt C'r a;t_` t:,s -ur cn rS Lhc'o c c r t Carszll}'c: ::c::::d 3 N- -ploy=un,, tlr tr.(FLI52s5!(5)?,r.f.r._::ia;by n hntncox,�cr for n Lcc c cY p:rmi: legal rtatuc of an cmplo)a utnurr 11:o Wctiicic o:;wnation?.cL I uMt _rrt...nd Chit a copy of this cIalc.:st esy t-.o fc,-'— --i to L»IY_txirvxrn:oft LriJ A4zi&=!Y 0;1_1 o of i'=a.'rc.:':a for lfx coverage vcxisctioc and ih-t f..iltuc to 25A of MG1,152 can lc-d to the impositiono(c r_!peral;:cs c0<nistutgof a fttr_ofup to S 1,500,00 nr.:.'Cv in tr„r, of up to cr.:} ;xtu R7n e:-.j C < u nn� f rtc of S I O.D.W day tg:ui.z m:. Fc c iq uvirltnl u.c v:7y tonaturc t�fl,ic�n:cJI'crnr,uc; ? :ii .' f _ n SCT10N;8 CONSTRUCTION:SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : � d/0- (� Z—(J�'►�er- License Number Address T /G /� Expiration Date Signature Telephone e .e '•om nt• ve: n wn#racto Not Applicable ❑ Company Name Registration Number Address , Expiration Date Tep� e �� sSECT�010�YVORKERS' COMPENSATION INS,I)RANCExAFFIDAVIT(M:G:L c. 152, § 250-(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 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 resp nsibility for compliance with the State Building Code,City of Northampton Ordinances, State and Local Zo 'no Law nd State of Massachusetts General Laws Annotated. Homeowner Signature ECTON5� 'S, R ITT ONt©. PROPOSEDYI►ORK checkll a {+table gfi New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Acc s ry Idg. Demolition❑ New Signs [ J 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 0- Sheet 0 aka fie:ou e,an or :ition toae fisting ho sin d; coif plereffh llM : 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 ®1 lifl ERIAU #tORIZATION TO BE COMPLETED VYHEN 0!YNEf�S AGEN �fCONT1?ACTOR APPLIES FOR BUILDING PERMIT I as Owner of the subject property hereby authorize to ac. or my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date I, 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 o Owner/ gent Date A 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 35// Frontage Setbacks Front Side L: R- L:Z2�-7 R: 7 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_ I� 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 i/ 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 y 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: w d4y,-O-Northampton - _.�z. ltdlrn `De p artment � 212 tVlain Street NOV - 4 2003 Room 100 Northampt';on, MA 01060 I -- *-c 4i-3.5$7-1240 Fax 413-587.1272 ^TG's APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 11- SITE INFORMATION 1.1 Property Address: f�aThis sectfo to"b„ comp elegy y offacl '- h 4eZ Zon ®ve J Dts .� � " ,� SECTION 2 PROPERTY:"OWNERSHIP%AUTt.i ED AGENT 2.1 Owner of Record: /V"Z/ Name(Print) Current V*l V-4_ 6'wof -C)/(// / Telephone s Signature -5-P Z (1 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECT90N".3i ESTIMATEEi CONSTROCTION CGSTS Item Estimated Cost (Dollars)to be Official Use Only completed by ermit applicant 1. Building �` (a) Building Permit Fee 7 , J 2. Ele .rical (b) .Ftimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5)] ,?Q TF, 7 S Check Number This Section For Official Use Only Building Permit Number: TDate'ls:sued: Signature: Building Commissioner/Inspector of Buildings Date File#BP-2004-0542 APPLICANT/CONTACT PERSON GREENE LORENZO&WILFRID R ADDRESS/PHONE P O BOX 141 (413)587-9949 Q PROPERTY LOCATION 72 OAK ST MAP 17A PARCEL 264 001 ZONE URB THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid Typeof Construction:_ERECT 10)C 12 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 F LLOWING 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 Co ssion Signatu e 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. • w u� T BP-2004-0542 GIs#: COMMONWEALTH OF MASSACHUSETTS P ovk,41A,L,264 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category BUILDING PERMIT Permit# BP-2004-0542 Proiect# ]S-2004-0765 Est. Cost: $2080.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 13503.60 Owner: GREENE LORENZO&WILFRID R Zoning URB Applicant: GREENE LORENZO & WILFRID R AT. 72 OAK ST Applicant Address: Phone: Insurance: P O BOX 141 (413) 587-9949 O NORTHAMPTON MAO 1061-0141 ISSUED ON:11114103 0:00:00 TO PERFORM THE FOLLOWING WORK.-ERECT 10 X 12 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 11/14/03 0:00:00 4431 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo