29-314 (2) CHEQUERS'"BY NORCOM
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CHEQUERS`"'BY NORCOM
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '>a
Nortli,,unpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as hds/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 roueh 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, (1 understand the above.
(Home own r/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 % �-� bo y ��
o re n rn c),
�•�tVJ-fps, '
B E Gif3 Jaf f1�i31111JfD11 - _-
A � E �;ISawcrinscfta' - _
DEPAR-FMENT OP BUIL.Dr\'C INSPECTION'S -
212 Alain Strcct Municipal Building '
Northampton, Mass. 01060
` `OI21Q IZ'S COMTENSATION GgSU LAINCE A=, ANTI T
I
(liccn permlticc)
\VIth a plz-tcipal place of business/residence zt:
(srrmz/ci ty/st=/Z)p)
do hereby certify, under the pz-ins and penalties of pefJury.; hal
i
( ) I an an employer providing the followine workcr's compensa io, covcm-e for In)
etvployces working on tills job:
-
(nsuac Conrsr) (Pclic: N t>_ r) -- (r.pirztior, Dom)
O I am a sole proprietor, general contractor or homeowner(ccie one) and gave hired
the cootractprs listed below wbo hive the folio%Yzng worker's compen�aon policies:
(i+amc 01 Co„^cior) GnR?ranc; CoInD3,1)'/!OUci !"'UQbc ) (Y-`.:mmuon Datc)
i
(Name of Contraaor) (Insurance Comoama?obc-, \tlzncrr) (Lipirtion Die)
(Name of COUEMC10:) (Lau -ancc C:om /Pot; Namlu) (Expir600 Datc)
T�-o)- n'
(Name of Contractor) (Insurance Company/Policy Numbr) (Expi-,6on DaLc).
(-n'ah.Idditi—1 ch—if uccta._^y to¢�cu inCorml�oa persa' io..11 ooa:r-�o:-�)
{ ) I am a sole proprietor and have no one worldDg for me.
I am.a home owner performing ail the Nvork myself.
NOTE:plea be 11—M 11”-tJe bccxDa-vcn,-to employ gc-swi w do cam.-=-z=oo cr rr,au--'0M on
a0c moot lb-Ll—unit is wb3ch the bctnoovroc raids or txi the p-oe:nca L:T cx10 be fi y
e ploycl ttt 2 e the..ups ocmpc t oa Act(GL152=l(5)�a4Vlta600 by a bomcoava for:6-r--Or a Pamir rr_y c-rae tt`c
Ic-al a--of—==ployer under dao WocScdc Co¢pamuioa Act
I uadersu-oC dva a copy of thiu mt®cm m y be Jr.,.ded to tho Depe,tmeo¢of todurriJ AO=&c Office of 4au—ror tbe
eavera,se�eiGessioa a_�lh1 L-iytae to soeurc'coveYn�tradc_r sxtion 25A of 1.SOL 152 ein iad to the isr�osstioa o(cimia�l peailtia
co=i:r z of a rinc orup to S 1}op-oo androc 6=pitioamc=oCup to oac yc and 6%il peaattia to 6c form of a Stop Wort;Order and.
Gm 0(SIDOM I d:y tpian tnc
.i"?---- For dcp.rttx.�.�vx only
( TNv-, Pcr='[Numb=
Lot .
Sites-ttum of Li crmittcc ��e
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
S.Registered Home Improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.162,§26C(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...... ❑
11. - Home Owner Exemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellines 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 �Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature C councn
J
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) �` Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [Q Siding[❑] Other[❑]
Brief Description of Proppsed
Work: 006-0
Alteration of existing bedroom Yes --""No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ✓No
Plans Attached Roll -Sheet
6a. If'.New house and or addition to existing housing, complete the followina:
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, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, rar V ClIt I'y-y-) as Owner/Authorized
Agent hereby declale 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 enalties of perjury.
I
Pri e
),C ' Q�
Signature of Owner/Agent I Oate
Section 4. ZONING All Information 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
Frontage
Setbacks Front
Side U R:•, L:! ,...,._ R.
Rear _... .. .'.
Building Height
Bldg. Square Footage � % � " '
Open Space Footage W
(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 DONT KNOW Q YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Pages and/or Document#;
B. Does the site contain a brook, body of water or wetlands? NO kA DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q , 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 Q NO
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 Q NOS
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
V
r.. % Department use only
Cit��f Northampton Status of Pert ft
A y
rLdOb Building 4epartment Curb CutlDnveway Pere _
M Main Street Sewer/Sap tic flvallabtiity
OVA, Watell tom 100 Wbli :=
'Northampton, MA 01060 Two$ ts�of Structural Hans
phone 413-587-1240 Fax 413-587-1272 P10tv/Site Plans y.'
Other Sp cify- �
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office'
.gal Map Lot Unit
1"5 i ` � C � Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
NameP ipt� Current Mailing Address:
1�L Telephone
Signature
2.2 Authorized Agent:
Name(Print Current Mailing Address:
6-� t/
Sign re Telephone
SECTION 3'-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building �,G t"L9 (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 d
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
d' e
File#BP-2007-0112
APPLICANT/CONTACT PERSON CANON TRACY L
ADDRESS/PHONE 324 ACREBROOK DR FLORENCE (413)584-8262 Q
PROPERTY LOCATION 324 ACREBROOK DR
MAP 29 PARCEL 314 001 ZONE URA/WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING 1 0 R FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Tyneof Construction: REMOVE 1/2 WALL REPLACE COUNTERS&FLOOR
New Construction
Non Structural interior renovations
Addition to Existing -
Acc_ n Structure
Building Plans Included:
Ov i-.c i Statement or License
3 sets oPPlans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 1 ION PRESENTED:
App, Additional permits required(see below)
PL:`. ING BOARD PERMIT REQUIRED UNDER:§
lntcr; Project: Site Plan AND/OR Special Permit With Site Plan
\Major Project: Site Plan AND/OR Special Permit With Site Plan
ZC ; ; BOARD PERMIT REQUIRED UNDER: §
Fin e i u Special Permit Variance*
i:eceived&Recorded at Registry of Deeds Proof Enclosed
Otlicr i�uwits Required:
_Lab Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
r mlit from Conservation Commission Permit from CB Architecture Committee
anit from Elm Street Commissio
Z- 2014&
§17g-nature, u i!!i ng Official Date
Note:Issu: a Zoning permit does not relieve a applicant's burden to comply with all zoning
requireinc: :, ud obtain all required permits from Board of Health,Conservation Commission,Department
of public ,ud other applicable permit granting authorities.
*Varian iiated only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning >pment for more information.
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