38B-047 I :( pi,
,#) � �` � rf of orthant tort i- -=* °
#4 �;,�. 'ill ; ,. c� 't .. = /
}n� ,► • • r�i je a 55achllsetts • = --
W: "= DEPARTMENT OF BUILDING INSPECTIONS l '� ==_ _
INSPECTOR 212 Main Street • Municipal Building > — ..' •
Northampton, MA 01060 .
e
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 ,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 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 tegulations. 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
�ttn}r
Pi. r ..
�° e - °ti (riLT t? Northampton G =
V f gt csakchnccf70 •
•
•
— DEPARTMENT T OP nuir_o J\C INSPECTIONS •
212 Main Street Municipal Building
Northampton, Mass. 01060 r ' -
WORICILIt'S COMTENSATION NSURA.NC.L AFFIDAVIT
e�Urr �,L.J rte'
( 7i ccnsccclpermi tttx )
with a principal place of business/residence at: 444
,4 ♦ ,'iA` -� L . +9 ' (on e ') (y U7 6
(sn - mot /ci ty /sla.tcfa p)
do hereby certify, under the pains and penalties of perjury:, :hat
( ) I am an employer providing the following worker's cornocnscdon coverage for my
employees wor dng on this job:
•
(Ingo Company) lPolic: Nuuabcr) (T :•pirmion Dai )
( ) I am a sole proprietor, general contractor or homeowner (circie one) and have hired
the coon listed below who have the following worker's comoen_aion policies:
-
(Name of Con':: ct01 (In urnnc.; Colnpany /Polio Numbcr) (r?:pira on Date)
•
(Name of Conn - actor) (Insurancc. Compa vPoiic Nunb r) (ExDiraiion Due)
•
(Name of Conraac oc) (Lrisul - a-nca Company/Policy N•asb`r) (Expiration Dale)
•
(Name of Contractor) (Lnsuranca Company/Policy Numb:r) (Expiration Daft) .
(anscb sddiv ilncoaa v w into& inform pcstasainS to .1r orccm..o:s)
I am a sole proprietor and have no one worldng for me-
I ( ) I am,a home owner performing all the work myself.
NOTE: pls=sc be awsrc the v{ j 6emca cvcra wbo accplcy pc-soul to do r s -' cs c wo c rcpair Boric on . d..cn ^i: of
not most th_a LS I>: =its in u'.ad, the bomrwwocr raid, of co the grouncS sppurteanm thctn s.rt no( eecrd - •t+i to be
c irployc- unCC the wca-1-..crt core --*•oo Act (GL152. 1(5)) rpp lint; oo by a bomeoava for c Ge ^v or po-mrt ter e-vidmx tl,c
lcg�f
ctan.ac of an erployer under dso Wock.ola Compcmalioa Ad
r uadcYtaatt dada copy of lLia mt®vd oo..y be f o r e wiled b the r?c-partmcol of 1 •*' +ial A c o a n s s & O f I oo of I 'D for t6.
env - zgc v c iioo a id th1 f1tUt= to socarc l:ovcraso under soczion 25A of MOL 151 ne lei o the imposition of ai i i pin•)tic
000sisseg of a fiat of up to S 1...S00 .00 andior iacprisocroacmt of up to ooc yctr r-ad dvii p=u- is in to form of a Stop Work Or and a
fiia o(Si 00.00 a day aptian tnc.
� .., For dcp.rt ux only
Pc- mit Number
41if V i\t1 -- Lot K f
Si Ena • / of Li crmiucc Date _ _ - J
•
SECTION 8 8- CONSTRLJCTION SERVICES ,
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
4 `Ciltileie ;Pr o °_ w , • etnen " 'o , ,t hm . Not Applicable ❑
Co e an ll.1 3 L I Cam--
J Registration Numb
i - dar‘ . Emil.
Address /� / Sr xpiration Date
, � ,fV 4 O/ ✓ _ 3 Telephone T( 6 U a&
SECTION 10- WORKERS' INSURANCE A'FFIDAVtT (M G:.. c.152, S: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 buyermit.
Signed Affidavit Attached Yes No ❑
N I, i 1 tt °@ 6 _.. e 13. r i A -
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 1083.5.1.
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 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 n ; Replacement Windows Alteration(s) ❑ Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0] , Decks [0 Siding [ID] Other [El
Brief Description of Proposed
Work: -'111 i Ski F-(2)
Alteration of existing bedroom Yes "'No Adding new bedroom Yes
Attached Narrative Renovating unfinished basement Yes
Plans Attached Roll - Sheet
Ga 'iasO 6 L "s : • . io o ?ex ®s o e Slll • e'mp1ete h toNl inci:
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 WHEN
OWNERS- AGENT;ORRCONTRACTOR'APPLIES FORBUILDING=PERMIT
1 \ f�
I, ' C -) ✓ ` K li TIYI,)& k‘ , as Owner of the subject
property �]� �� i _
hereby authorize Ir'�C• u� W�
to - , '.n . hal i all Inat rs relative to work authorized by this building permit applic ion.
Si na - f O ner Date
l _ _.. ' ; v , as Owner /Authorized
Agen th- a d 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.
Pri - -e
•-gnat - of Owner /Ag- Date
Section 4. ZONING All Informatibft 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 i
Frontage ( I i ` l
Setbacks Front i t f
Side L: R:� Li i R:: .
Rear i I
Building Height ;
Bldg. Square Footage 1 1% f I i i
Open Space Footage %
(Lot area minus bldg & paved i i - 1 =
parking) .
# of Parking Spaces
i
Fill: F
it
(volume'& Location)
A. Ha_ s a Special Permit /Variance /Finding a er been issued for /on the site?
NO 0 DONT KNOW YES 0 '
IF YES, date issued:
IF YES: Was the permit recorded at the Regist Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page' and /or Document # j
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained I Obtained Date Issued:
C. Do any signs exist on the property? YES 0 NO •
IF YES, describe size, type and location: 1
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: t
E. Will the construction activity disturb (clearing, grading, excava ' , or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES r NO
I
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
r
City of Northampton l � , ' �: 1 : } '
Building Department - ' _ � � ?
212 Main Street . 1 :: : -
Room 100' � - ���,
Northampton, � 01060 ° ` ,
phone 413- 587 -1240 Fax 413- 587 -1272 ,
= - .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, REND A - O O IS A MT - TWO FAMILY DWELLING
i
SECTION_1. - SITE fNFORMATION g �
1.1 Property Address: 9 � r T 1is arr t mpleted ffice
�. l ,' A c dy „ 7� t -' s :
k) � � �/�y� e
O c \v^o"^^ r / mil--- _ - net, ,V ; «� '.'• , ®a 3Dis
E x-. Dis ': `� : ` : ° '''�,CB Di ..
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AG
2.1 Owner of Record:
Pc 1 V-, ► lr.( 1Awer k vat s,,„F19,
N Print) Current Mailing Address:
y/3 '2.51 -/6 C Telephone
Signatur
2.2 Authorized Agent:
L,uL 1 H t! 3
N. e'(Print) Current Mailing Address: /
.,,,,,,z, /i l l � 8/
*atur= ' Telephone
SECTION 3 - ESTIMATED COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
{a) Building Permit Fee
1. Building I\
I
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) 1 �7V
Check Number
' This Section For Official Use Only
Date . .
Building Permit Number: Issued:
Signature: r
1
Building Commissioner/Inspector of Buildings Date
#.
9 LYMAN RD BP- 2005 -1255
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38B - 047 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit # BP- 2005 -1255
Project # JS- 2005 -1671
Est. Cost: $11400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DOUGLAS B LUCE 136057
Lot Size(sq. ft.): 5183.64 Owner: KIRSCHNER DOROTHY B
Zoning: URB Applicant: DOUGLAS B LUCE
AT: 9 LYMAN RD
Applicant Address: Phone: Insurance:
122 AUDUBON RD (413) 584 -8786
LEEDSMA01053 ISSUED ON :6/14/05 0 :00 :00
TO PERFORM THE FOLLOWING WORK :STRIP & SHINGLE 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: Date Paid: Amount:
Building 6/14/05 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo