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17C-256 (3) 4'S11AA1P�. �85EACt(li8[tt6 - d 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 his/her construction sups. ,,i sor. T he 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 rouizh 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 } � 8 ri�:aaxrflttsrtf� ff > r=7 DEPARTMENT OF EUILDI?�G INSPECTIONS 212 Main Street ' Municipal Building Northampton, Mass. 01060 WORKER'S CO1,14PENI SA'MIN INSURANCE Al,FIDAVI.T i %with a principal place of bus1ress/r,2sldeuce ldlhone '} (StTCCUC;I '......1:/"iii)------- -- - ------..� cio hcreU}` CCrill}, t!nClcf" the 1)?.1i1S 2i7(3 pCi7 iilCS ni pe;rJtlfy i.Ili!i: O I am an employer providing the followint v.,orr_er'-s comp nsarioll coves'-�.c or my t;111()10yccs wor'Klrl on tubs job (ln =C.n Comp=y) c C- N t I M,bcr) — (Expir Lion Date) ( j I am a sole proprit tor, genera conk or or t:onlco.vner (c;icie one) and l:a.,e 'tired tl1" contractors IisteC below 1} 0 i; the tfJ1 .-� v or ite S coiIlpeIl 101-1 o!1c!tS: (- amc of Contactor) Dmc) (Name of Contrctor) -- r711sJ :race Con p .�,Pe!ie; Nlntrr) (I ?: i- tioa Date) (Name of Contractor) — (lILS'�li1C^ (_O :'_il'i/i�0!.Cr T�11Ji]1}_Il 'X.iiC: O 1,atc) - (N `of Contractor) —- jnS1:i-LjI1C_ CoIL11-7}`POUC-V Numhr_r) ^:t1Lt �3t:CY:17 5::;�t...._'_.. ::] ......�.......:K:..a....� ,�._.... � _ell_:...-..._...• ( I I1IT1 11 OlC l)1"U4)rl"CJi i'.iIQ hL-1,C 110 one- tot- ?II". <? home 0vVI1C': i)CiIC -.l?1111 111 *JO"I�::please t>c nt��:c t}s:•.��•ilc F.c<;�o�+1r_n•.� -o c_,�!�;:1--t:-::::n:'o��c:_:.uac�ar::_n:r_��-n cr:c,�air�>-,:i:,r_�«cl!i::�'. not uxre Lh a L reo Lmis in ut `t he t r.,�;uZ,�rte; s u<a;'` ✓:.-.�z uricr r I LhcC.o e c ext Ec xr�lly cc ::: :c h catptoyc-3 uz&cr tFr tvc:�'�s ca --;_tire itc'(C)L.!S2 ;!(51 ,-r•1:_„ic:.^y n homco,,'txr for n l ccu Icgal ctat)jc of nn caxptoyer under tt:o Woriccfa Con:;oration!.cy- 1 uz--8--zta d dlt a copy of!lui ctita:c_•may bo fau v o-I to tt»tY_Sxi tzrs> of I1-dzuiricl Ac6,,. &Gifcv of is :rar_o for tlx coverlgc va-if c:1i0O and that tathttc tO!--”-m4 r y1- ci.IM 15A of?.tGi.152 can lead to tlx imposition misting of a rtnc of up to S 1,500-00 nrJ Y i :pr Z :_of::p to c1-,:y -_j civil xrutl a in c tc r n c(a S!�,`•VMY.Ch�_:d Lr�of S1 00.W a dsy glut):.1 m:. Fr,c $r�uutYrtal u.c c.,ty v 1 �3 I -cick�� Pcrrnit 5t r;vaturC Of l.icCnr CJPcrn,;a1-. SECTION 8 CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holde ba"j,'/ 6rt,,e, — (� C J� p License Number / h jAddress �OX C,5- 4?ry eJ d /0 Expiration Date gnature Telephone ( j Regis a orne mprovement �.a'., Not Applicable ❑ Company Name Registration Number Address Expiratiod Date pTelephone SECTIOPf 10 1NORKERS' COMPENSATION INSURANCE�AFFIDAVIT(M.G.L.z. 15!2, § 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: 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 SECTIOAYS=D S R:1PTONOFPsROPOSED�aiYORK check a11:a licaile New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ J Brief Description of Proposed Work: Alteration of existing bedroom Yes No Adding new bedroom Yes No / Attached Narrative D Renovating unfinished basement Yes c/ No Plans Attached Roll 0 • Sheet 0 6a <fi teHr e �11i tlit on exiistin-SOM int°�co I:e fhe fiot°lawcn:: 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?­L41eS rl � 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 . 1. Septic Tank City Sewer Private well City water Supply SECT101 " ��IR�UHORIZATION 'TO BE COMPLETED WHEN OWNERS AGENT O�XNTRACTOR APPLIES FOR SUIT DING PERMIT as Owner of the subject property hereby authorize /G k�q 1�Gt WSOyt - Pki to act on my behalf,an a ma lative tQ work authorized by this building permit application. Z-�­zw(-,Lo Signature of Owner Dat a OOwwneV/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accuCate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Prints Na e -� Signature of!Owner Agent Date 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 Sp ial 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 Com ssion? 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: . ... .............. . City of Northampton ',Building Department ` 212 Main Street ` Room 100 a - No`Irthampton, MA 01060 e —Pt ione�413A587-1240 Fax 413-587-1272 t. kPPOCATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1- SITE INFORMATION ... ;, This secttorita becompfe#edbyAo#fic"e� " 1.1 Property Address: / r1 �f Lot' tt r`qg Zone O'verlaDistrtct . i rC H L C M A , Pg ' � H� , .k�y, '.h "' t Elm St District CB Des rict� SECTION 2 - PROPERTY OWNERSHIPZAUTHO,R:IZED AGENT %r 2.1 Owner of Record: f Name(P int}• � t C ent ailing Address: Telephone Signature _ 2.2 Authorized Agent: y, was V N 6 re f n-2 (Y/ ' i'` .,� � 8 orJ3'z C N me Print) Current Mailing Address: JAI Y Signature Telephone 5E0TION-:3 -fSTIMATED CONSTRUCTION<'COSTS 77 Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant - 1. Buildings (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 i Building Permit Number: TDatelssued; Signature: I' Building Commissioner/Inspector of Buildings _ Date' r 46 iL 1"H MAN ST � BP-2004-0453 GIS#: COMMONWEALTH OF MASSACHUSETTS A+an:Block: 17C-256 CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2004-0453 Project# JS-2004-0655 Est. Cost: $4000.00 Fee:$25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Tom Dawson-Greene 124106 Lot Size(sq.ft.): 22389.84 Owner: BRILL ELISSA Zoning:URB Applicant: Tom Dawson-Greene AT. 46 NORTH MAIN ST Applicant Address: Phone: Insurance: P O BOX 556 (413) 296-4421 CHESTERFIELDMA01012 ISSUED ON.10121103 0:00:00 TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE GARAGE & BREEZEWAY ROOF 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 10/21/03 0:00:00 8436 $25.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo