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m DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '
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
7
I, w understand the above,
(Home o er/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 2-,2-3- 0�-k
Address of work
location 3�J l AC r c 13 20 Q IS 1) f`
L=L o r L7 A1c_Gs- /LA ►°4 a i o(,;,'L..
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m DEPARTMENT OF LUILDP? G INSPECTIONS
212 Main Street • Municipal Buildirng
IN'orthampton, Mass. 01060
WORKER'S COi1'TENSATION INSURANCE AI MA IT
v"I"11 a principal place of business/residencc 1:
(ph:.nc'
(10 hereby Ccr- ly La:i'71 L11C 1);tlil$ and pC;il?1t1CS Oi pE;r�tll�r, illaE_
I
am an employer providin- the my
e112pl0yces working ran t}Sis job:
(Las-d ncy Comp m')
(PC;;c-, ?r1umE3cr) --- (F ir.:ion Date)
1 I ant a sole ro riet r, zene i � o - ' � i ;
p p o ra. c��n�c` r _omeo.�-ner ic.e one�i and .�e iuzec
t-11`.' CO(1 actors listed beio vr:i'li0 i1S. i11C' =0i1G,:.!; S COi U�nSc 0i1 O iC'CS:
:ame of Contnm nsu- Com�-:r, .P - -
r) (? _..ncc ;. olicl Nu.zniYr) t- ...�o- Datc)
(Name of Coati cto:) Nuncrr; CF' :ratio Date)
(Name of COIL—,actor) Com- v/Polio. Nturtf--r)
- (Name of Cont-actor) -- Qns ranc CO?P.'.'Wi}'rI'olie✓ Numb---) {I:xn -:ties Dale)
l
I t1II1 (. OIC 1)r01)Ilf COi 4111 huvc no
a 1:01110 0v'111C`r 111
NOTE ,lc:sc L-:aware
not uric th:z)4:zu uui+s in�,I di he E :..;;1z, r :—.-z o a, :�:_:.�z t•- c 1'Fu 0 c 2 n<Ecrralty ccr.:
cr.:ployc.3 urvj' t}x tvc;i,n's mrr.-r.._.ix Ac.'(GL1 (5);,a,: ._:!icr:by a hn:•iro«w for a l c c ct p-ra:i: n c
legal etatus
of=czxpl oyx under tin W vicli oa-;krr.!iaa?.ci
[uzw6 rTt, d the a copy of ah r�-y ho fo tivnzdod to c;�IY.{a t:cn of Indus ri 1 Ac�G�=�Lii v of for tlx
covcragc vcrificarioa and th-t f ii uc 2 S A of hi01.152 can lc i to Qx iailvsiiio t cf r, ir_1 pctsl:_u
coasiatina of a ftrr of up to s 1 50U.C�J n: ' t i :;iii :rZx:_of t:p to cr.:} t:.j evil psultiu in r for n of,S!r;,`;Je i.(h -rd-
LrW oCS100.00 a day 1geit A tn..
ror dcpa 11"lal u+c cn'y i
.`511;Z]A Ll11C t)1'1.lCC:):.CCJ1rC.CIll tt te_r:
SECTIOW ,CONSTRUCTION.SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
NReg s e ome mp" roiiemen Contractor Not Applicable ❑
Company Name Registration Number
Address
Expiration Date
Telephone
SEGTION30 WORKERS'.,COtYIPENSATION IN NC
SURAEAFFIDAVIT(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...... ❑
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"homeow-ner" 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, Stale and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Ho
eowner Signature � ���
AsECT101_5 V S 0 -TO FFPROROSED*ORK[check 11 apn'licable) �
Ji
«..
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑ �k
Accessory Bldg. 111 Demolition❑ New Signs [ ] Decks [ ] Sidin [ ] Other
Brief Description of Proposed Work:_A46-IN SfO URC- GO19QWG 34C ! $e P1_4CZ ,D o N S�'f�= loYlL
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 • Sheet 0
�I��w" hoarr�`n°� or atltlitron�to existrng�houin";?�.copse"T tef�iefolaow:in>7:
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 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
SECTIOP[7 �OltSINERAUTHORIZATION TO BE COMPLETED WHEN
OWNEkSAG TOR CONTRACTOR'gPPLIES FOR BUILDING PERMIT
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
as Owner/.Authorized Agent
hereby cleclake that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge Ynd belief.
Signed under the pains and penalties of perjury.
Print Name j� q
GrIq � A- eSG/v
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 S
Frontage
Setbacks Front
Side L: R: L:2AC—) R: A/
Rear /
Building Height 2,01
Bldg.Square Footage 7. 0 %
Open Space Footage %
(Lot area minus bldg&paved
parking) D
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT 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 properly?YES
No
IF YES, describe size, type and location:
E i of Northampton
Q ilding Department
12 Main Street
AUG 2 4 2004 Room 100
Nort ampton, MA 01060 r '-
DEPT OF BUILONG IN am 3413-5 7-1240 Fax 413-587-1272
N 31MN"PTON,MA 01060
� w
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Properly Address: _ a This sectiaix to fie completed by office
iY
lZ oo \
1. d RCS C L i1 49, ®/0 6 - Zori veilaY Dis et
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SECTION 2-PROPERTY OWNERSHIP/.AUTHORIZED AGENT
2.1 Owner of Record:
GARY A4. Lau0A-0-R+ T-cheSo .0 5`/2 _3,W,4Ck 8Roof(
Name(Print) Cpgent Mailing Address:
-1- o K&-/yci= M 4. o/oG Z- 3So3
Telephone
Signature (f qj S-&y S3
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 ermit applicant
1. Building 1 Z (a) Building Permit.Fee
1
2. Electrical (b),-Estimated_Total Cost of
Construction from 6
3. Plumbing guild,ing Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2+ 3+4+ 5) 1 12 . Cog Check Number
This Section For Official Use Only
Building Permit Number: Date issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0229
APPLICANT/CONTACT PERSON RITCHESON GARY A&LAURA E
ADDRESS/PHONE 341 ACREBROOK DR FLORENCE
PROPERTY LOCATION 341 ACREBROOr,DR
MAP 29 PARCEL 324 001 ZONE URA (0 G7Q
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
i
Ty_peof Construction:_ERECT 10 X 12 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9064ATION 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 Street Co ion
0000, 7/
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.
• '�f of
341 ACREBROOK DR BP-2005-0229
GIs#: COMMONWEALTH OF MASSACHUSETTS
M lock:29-324 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0229
Project# IS-2005-0281
Est.Cost: $2713.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 25439.04 Owner: RITCHESON GARY A&LAURA E
Zoning:URA A-pplicant: RITCHESON GARY A & LAURA E
AT. 341 ACREBROOK DR
Applicant Address: Phone: Insurance:
341 ACREBROOK DR O 584-5334 O
FLORENCEMA01062 ISSUED ON:8130104 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 10 X 12 SHED
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 Occupanc y si nature:
Feel e: Receipt No: Date Paid: Check No: Amount:
Building 8/30/04 0:00:00 184 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo