29-485 ��tU►MP�. C;
g ~$ Grif r of Nort4autpton
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m DEPARTMENT OF BUILDITIG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sup(,, ,,*.-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 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, 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
v 'A# -''
0 0
I>7z-f(J�tllt}�tLill
6 3 OftC11 11 6Cl15
s L)EPARTMENT-T OF EtUILDDI G INSPECTIONS —
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S CO-MTENSATION 1-NSU1Z.ANCE: AFFEDANI.T
1� ------Air!'=-�Z-?�-_!`����Z----------------- -- _ _ ------ --- ---
v"111) a principal place of busiresshcsidencC t:
do 11CI'eby cCrill)-, l'IlC'Cr the 1paills Zlnil l)Ci]?it1C`; of pCt�uty, ihF!i
( ) I an employe; providing the `ollo"i"int '.=.orr_ers compensation cove.a�"(" ror Iny
C 1ployces ,voridng on t-lis job:
(InslranG Contry) e .Nttrnbcr) --- (r3.�,irticn Date)
( ) I acs a sole proprietor, general ccn,,�mccer loo:eowoer (circle Oct) and 't:a 'e tvred
the contractors hsted beio','r' '.i'lio i12 ILI) lG .i• ''OrkP�S Goi]J°IIC3�Oi1 '�o!)c'.ts:
(Na c of Conmacior) (?ricU ,]C CCI n".:ir;PG11c NUSTIbcr) T? :.1G' Datc)
(Name ofContr:cto-) N=,b,-r) (I `:ri'aiion. Date)
(Name of Contractor) (Inslr ilc� C.� -anyi;'olic; NUII]bIr) ~.x,:r. dGa Date)
- (Name of Confmctor) - (Iasl anc� Comr- y/Pohr--y Numb,--r) (E:;:ri-tier Date)
I iLll it SOlC prUl?I1CtJi 2i1;1 have 110
(_ . , ot ll�
I?iIl 1011e a1( i
II It
7 (,
NOTE:plcasc tic Aw:UC ti:st.a?:i)c h<;�oanrn a ,o c ! :.::-� m o-r:cPair a __.._daacl!in�c.
not tneee than throe uni'"I in ta1.:;dt e f; ice.:tizv zr:,:�cx a;'` ;:^�_ •_ricr�rl Lhcro c 2 Y��ersally c: •':
c�ployc�u_ cr t}x avc;:a'c cc •�: ±i n i 2 (C Ll Sw31(Sj`•':._a;i ;,v a her oavncr fort Lc-c_,c c<
legal statue of an amployx to pert n V'c�c�i i-xt—, •:.lion AcL
I undo-nat d th.t a cony of this s:stc's mvy bo fcx— ,I—j to tl o tY_t utzrn of L dzulriJ M�d�:t Cir,w of is a r c for tx
ooverage vciGciioo and that f l u e tc rrauc m�� g ur d:sc�.iM 25A of?.{GI.152 can lc--d to the mposition 1 r ir, pawl::es
eomisti g of a fssr-of up to S I- CWQO an.''rr i-:;tr:vxzti:_of!!P to Cr.-.}- e:.j civil xTU16Cj In fcnn of n Stc;,%Vr-ri.C}-a: _:-,d
f T>r of!;10;).00 K dsy K gain:t m:.
For itrzi�tal urc«ily
' � Pcrrnit ilttmb'=-r ___
..,. ()f i tcc•t';cJPcrnr'rr,•
1 ., .:
SECT�ON'8 CONS�RUCTION'SERVICES
8.1 Licensed Construction Supervisor: 1 . Not Applicable 0
Name of License Holder : �A'ri'��x� ". e r)G�
License Number
C-5 o�,q 2
Addre 6 lot, � Expiration Date
Signature Telephone
.Re : ve en r.0 'ntracto _ Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SEC_TION10 WO'yRKERS' COMPENSATION 1NSURANCEAFFIDAVIT{M:G.L.,c. 152, § 25tr(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....... 09- - No...... ❑
. MW
ix III ,
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"homeoNvner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she sha11 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
f '
ENO
SET ®_ �DE ` R rJ�NOFROPOSED WORK checVt.fl I�cable '
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ DemolitioAl New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: eell4a IZ I o ' -tipeks",
Alteration of existing bedroom Yes No Adding new bedroom Yes -- �- No ,
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll ❑• Sheet
6a, , :.e:: _a V n 6. addition�to, ez sting housing pJe�e t e fol owe:g
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
SCT�OTIatfl�lERAUHORIZATION TO BE COMPLETED WHEN
OYYNffdS �,ENrCONTRACTOR APPLIES FOR BUILDING PERMIT
�� 1"�f� '�► as Owner of the subject property
hereby authorize ?A+A, V2� LH— S � to ac; or
my behalf, in all matters relative)to work authorized by this building permit application.
Signature o Owner Date
I, �PO4t P->el"m/ 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 a
Signature of Owner/Agent Date 11111 �
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 Special Permit/Variance/Finding ever been issued for/on the site?
NO 0( 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 Commission?
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:
r ley of Northampton
41ding Department
r-
212 Main Street
Room 100
Northampton, MA 01060
_one 4.13.587f 1240 Fax 413-587.1272 .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I - SITE INFORMATION
<' TI]ISu5eCtlO t0beCDtil Etewdbycifflce I
1.1 Property Address: ai , �y � �
(
! Ma
n
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1�1 '� �, ru �W t,� ��
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:
Elm StDlstrlcf CBDIS rlct
SECTION'2- PRO.PERTY:OWNERSHIP%AUTHO,RIZED AGENT
2.1 Owner of Record:
�kr'tk S51a ( vk�Pilo t14 Ste~ u rs P, �a
�T
Nam ( rint) Cu rent M � ,Address:
J Telephone
signatur �'3 �j (� �� Z,!A
a
2.2 Authorized A en
_q a
Nam 1 t) � Current Mai!ing Add_CA�-�--
Sig ature (e Telephone l
SECTION3 - ESTIMATED CONSTRUCTION COSTS`
Item Estimated Cost(Dollars) to be Official Use'Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) atimated Total Cost.of
Construction,from 6
3. Plumbing Building Permit Fee
J 4. Mechanical (HVAC)
15. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
,This Section For Official Use Only
Bolding:Permit Namber: Date l"ssued:
Signature:' _
Building Commissioner/Inspector of Buildings Date
w4fto .-
File#BP-2004-0600
APPLICANT/CONTACT PERSON Pamela LeBeau
ADDRESS/PHONE 248 Bryant St CHESTERFIELD (413)296-4506
PROPERTY LOCATION 584 BURTS PIT RD
MAP 29 PARCEL 485 001 ZONE SR
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 5 L �1�`'
Typeof Construction: DEMO 10 X 14 ATT SCREEN PORCH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building_Plans Included:
Owner/Statement or License 064756
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF,QRMATION 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 Stree ommission
/ L
Signature of Bui ding 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.
414k*
584 BURTS PIT RD BP-2004-0600
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-485 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category: BUILDING PERMIT
Permit# BP-2004-0600
Project# IS-2004-0851
Est. Cost: $2000.00
Fee: $15.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Pamela LeBeau 064756
Lot Size(sq.ft.): 30796.92 Owner: LAMPRON MELISSA J&
Zoning: SR Applicant: Pamela LeBeau
AT. 584 BURTS PIT RD
Applicant Address: Phone: Insurance:
248 Bryant St (413) 296-4506
CHESTERFIELDMA01012 ISSUED ON:11119103 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMO 10 X 14 ATT SCREEN PORCH
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 Si nature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 11/19/03 0:00:00 2931 $15.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo