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DEPARTMENT OF BUILDING INSPECTIONS 4 _=___ /;
212 Main Street • Municipal Building >a
INSPECTOR '" ,•
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 sups:,'isor. 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 the project until such time as the proper permits and inspections are
made
I, 02' 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 2/11/6t -
Address of work
location _S-7 ,e.,7%,,„ /` /rl
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p- DEPART MEI-IT OP BUiwr�G INSPECTIONS . - •
—
212 Main Street ' Municipal Building
Northampton, Mass. 01060 r` '
- WORMERS CO MP ENS A`ITO.N 1LNSUR.A.NC1'. AFFII)AVIT
•
L1 -- _ .__ _ ._. --- ---
(li ccnsxJper mitree)
%t.rith a principal place of business/residence at:
s°7 7/mac/ d Zr7-,ls i h-i lei- 0/0s"3 (l;honeiC0 S°YG- c ,
(s-a .tici ty/stalcia p)
do hereby certify, under the pains and penalties of perjury, the
j ( ) I am an employer providing the following kmorircr's compensation coverage For my
employees worng on this job:
f_
(Lcu.ranc Corer=.') (Policy Number) :pin-aim Dal- ) -
j
( ) I am a sole proprietor, general contraaor o otneovne9(c cie one) and have hired
the conn-actors lined below two have the following worker's comoe?auon policies:
/V.srWrc Z7e-e Nat,.oiyik (-t rar OIL)\--Lvt..S '9 I I I C)(''
(N+ern(of Contractor) (Insurance Coinp yi?otici Nu r±cj -': trauoi Onto)
...--, ,...____2„.. .. 0096 . b3" 7/.2 lc b' -
(Name of Contraaor) (l.nsuranc CompaavPoicv Number) (Ex-pinion Dale)
(Name of Conn-ado:) (I=suranc Company/PoLic-- Number) CExpiroon Date)
{ -
(Name of Contractor) (Insurance ComrzQy/Policy Number) (Expiration Date).
(att.lt d od 6..L.- do,—.--tc cnciu—inform,... oo ._ to.11 c--cons) .
-
( ) I am _a sole-proprietor and have no one working for me-
( ) I am,a home owner performing all the work myself.
NOTE:press 1x ,-4.rt the w'.^.:c boc=co..vc:-s v.•)ys=play➢=••.om to do r-•ter-•,•,-•-cs-CJoo a r'ir...ark oa s d..<rt:^c of
one mote tt_t a 1...."0.tars is uticta the bomoowvc mid=or oa the Qwa ,N.Ctca_=tbeeo c:oat c-=.---ally Doe=d.-ni to be
ciploy - ua;=the..ui;e':ems—r_ -oa pp(GL152 1(5)),.pptiiioo by a bommax f=c G ^v or pcmrt'-y e'-rdmce Lb.:
1cgs.1 r-"^u or en o ttoyor uddertt,o Worfda Coaxpccr,lioa I,,,
I unS -o..yd thi¢n copy of thi,caturcocol cony b.for.oc rd.d to the Dcportta st of lodusriJ noodeota'oe o.of lasu.noe for th.
oovczo^c N.c-irelioo r td th 1.ttatac to soauc 5xvcra.cc t,adc soction 25 A of MOL 152 ran icd to the iyposilioo of cimiat1 pro,hie
coazisai-zg or.fix of tp to S t S00.00.-n3ror of up to ox yr:r sod c.i1 pca,.tio to tSc form or.Stop Work Ord=and•
fire oa S i OO.00 L day.
- - For 6e�ars�J u+e Doty
permit Number
��//�5 ��/U (d t.-Iap=—_ Lot "_
Si n,ttun of LiccscfPcrmiu Date -- -
SECTION 8-CONSTRUCTION SERVICES s
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9�,Revsereimrc+wemer o :'v . " ; „ r Not Applicable ❑
Company Name Registration—NUT-1)n er
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 ❑
1 � >lu .wIl ,� 1 m}i
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 be/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,von 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 La d State of Massachusetts General Laws Annotated.
Homeowner Signature
•.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check alll applicable)
New House ❑ Addition ❑. Replacement Windows Alteration(s) E Roofing El
Or Doors CI
Accessory Bldg. ❑ Demolition El New Signs [0] Decks [Ej Siding[0] Other[;irtf
Brief Description of Proposed / , ._ /� Q
Work: /2trn D•.2- c.F�'' /i'r,/iK{ 4".k!r.✓ cRbfre�h Si 47/K G s iZ.,,,,L .
Alteration of existing bedroom / Yes tNo Adding new bedroom Yes I/ No
Attached Narrative Renovating unfinished basement Yes 4� No
Plans Attached Roll -Sheet
SW3""`d' `.:.. ws• , * ,,r. + ,rn - � =-a :c° f. .fir-, _ z
6a�fNewvhausea,nd-orattditioni,.extstrnghouslnq corn p ete#M ollovfnnq.
—
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 OR CONTRACTOR APPLIES FOR BUILDING.PERMIT
I, ---7- ,41 s 62-,.-VI, ,as Owner of the subject
property
hereby authorize /07 s-c/./
to act on my behalf,i matters rel ti to work authorized by this building permit application.
matters 24 % (
Signature of Owner Date
1 /,
h 6:2,,,...._- ,,,, ,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 pain --• ,,enaltieserjury. ,-
Print Name
Signature of Owner/Agent Date
Section 4. ZONING All Informatlbh 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
Setbacks Front j
Side L: ' R: L: R::
Rear '
Building Height ------
{
Bldg. Square Footage i I i I % 1 1 r ?
Open Space Footage , %
(Lot area minus bldg&paved i i i i 1 i
parking)
#of Parking Spaces
Fill: I 1
(volume&Location) f
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book Page i and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0- DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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 e,
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O r NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Departmentuse only
City of Northampton to #�e ' �
Building Department l JiA in
212 Main Street serer ,= '
n� Room 100
- ="'u�Iorthampton, MA 01060 0
phone 413-587-1240 Fax 413-587-1272 �
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be mpl
coeted byof ice
1.1 Property Address:
5.-__7 G'" /s,—t/ /to42C/ • Maps Lot . , Unit
� 5
d/CPs��
Z rrl�S /�� ZoneOverlayDistrtct
EIm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
■/v � .,�p U A61")t• iv?tf 7 Zrr<4, '' 4 e"Ve s
Name(Print)� Current Mailing Address:
Telephone
Signature
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 permit applicant
1. Building -Iti G ,� (a)Building Permit Fee
2. Electrical (ti)Estimated Total Cost of
Construction from(6)
3. Plumbing d „ Building Permit Fee
4. iviechanicai(HvAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) �/ S -- Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2006-0780
APPLICANT/CONTACT PERSON QUINN THOMAS F&AMY B
ADDRESS/PHONE P 0 BOX 247 LEEDS (413)586-0283 0
PROPERTY LOCATION 57 UPLAND RD
MAP 11A PARCEL 074 001 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 """J
Typeof Construction: REPLACE KITCH CABINETS, SINK&LIGHTS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
PRESENTED:
THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF A
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 • on
,�..._ : 2c eO o
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.
57 UPLAND RD BP-2006-0780
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 11A-074 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0780
Project# JS-2006-1190
Est.Cost: $7125.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 20124.72 Owner: QUINN THOMAS F&AMY B
Zoning:URA Applicant: QUINN THOMAS F & AMY B
AT: 57 UPLAND RD
Applicant Address: Phone: Insurance:
P 0 BOX 247 (413) 586-0283 0
LEEDSMA01053 ISSUED ON:2/7/2006 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE KITCH CABINETS, SINK & LIGHTS
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 2/7/2006 0:00:00 $50.001449
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo