29-359 04��MP0
$" � +,�iasaac}rusetta ^l
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
. S,.
Nortliarnpton, MA 01060
,r
HOME OWNER EXEMMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNM 1083.4 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 faini1y__-
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.
r t homeowner 1_',__ L .7.,.. .--4',. / t rnt nt mt-lmn R� rrnc the
I
the homeowner hires other trades to pellVrm worn`electric-mll riumbirlb F,_.)
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
"; 1. ✓Jlu.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 /.2 / /rq
-Address of work
/location -:2 y i
'jA . �2_
�.O �✓c--fie,�y _--�_
o OEPARTMENT OP BUIL00\1C INSPECTIONS
212 Main Strect hTunicipal Building
Northampton, Mass. 010GO
`ORICER'S COiAPENSATION MSUURA-NCE rt1�IILf)A,Vj7•..
(Ii Jpcm;i cfcc)
\vlth a principal place of businessfresidencc ac:
(phone')
do hereby certif);, under die.pz-ins and penalties of penury:, h:c
( ) I zra an employer providing the followinL'%vorkc's comocnsZ;io;: cove age for in)
emplovees wor Dog on this job:
(la5u-an=Conr,�) (PcLic: Ntt r) -- ( ;pirtior, D?L)
( ) I am a sole proprietor, geaeral contractor or ho¢-ieow-oer (title one) aBd have hued
the cone actors (fisted below cvbo have the folio%vi�Q worker's coEiioeD-taaon pc!icies:
(i+flIDe of Cont^eior) (I t1R!i�1. nC;L Compaq• -fiilGUc-, Namh<:) (Expilauop 1).11c)
- (Name of CooEmclor) (1nsarancc ComoaII':lPoUc-, Nuimm-^-r) (-Ex pir Lion Date)
(Name of Coanaclor) (Insurance (Expimdon Datc)
(Name of Contractor) (tnsu=c-- Ccmraay/PoLcy Numb-:r) Daft).
(nau3 ad.'lizocal 6c-- f acca. y to mead;infora oc pc to alas to.L coa=- -o:)
{ ) I am a sore proprietor and have no one worhdng for me.
I am.a home owner performing all the work myself.
NOTE:pl=.=be awut Th.,.{:.fie hca)=D very wto esptoy pc.cr=w do rgair work oa of
ant mat th-n t moo-_ors in«'aim the bomcowacr rca�or oQ the Q-ou ,gpurtco_rs tbc-. ,ooc�orlty oa�:d,-cd to Lx
cilployc-s uz,e—d---k=--C==p ,'m A�--(GUI 52.s 1(5)l by Fes' y
t^pliabon n 6otneoava fer:!ice__a t� n-idmcx the
Icgal ni sc of—arPloyo under tan Woricor.Coc:VOc a Act
i mad tha a oopy of thi.-tL m av y b.foa--d-d to tbo C�pvtmmt of Iodussiel Aoadeatj Offioe of for t6.
covcr'Z' vciLc=ioa-ad the C=Ium to"==bov,�uadc scctioQ 23A of).(GL 131 cia tcd to the iawaitioa of cimiaal pcan -
eomi.ing of.fine of t�to S 1 500.00:ndJa o f up to ooc y--3r end ci vu pm.Puo n x form of.Stop Wort Ordc nod.
fi=of S 100.00.day cpiaa ax-
For =�uK only
Permit Numbcr
..✓ �vt�... ? ';SSJ e',! N,(ZP. l.ot° is
S�tcun of icscc/PcctnitCc� Late, -- i
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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
9_:Registered"KbrneYmproverrient:Contractor " Not Applicable ❑
Company Name Registration Number -- --_
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 I .Homy Qwne>l-�Fa��>l��i�a %
The current exemption for"homeowners”was extended to include Owner-occupied D:yellines of one 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
orthampton 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 ❑; Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[o]
Al"rief Des�ption of Proposed f ) l J r
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa If New house and or adcf tiag to extstlnkti hausina comatete fhe foFfQWFnq:
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'Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES 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 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 Name
Signature of OwnerlAgent Date
,
, ~~
�
Section 4. ZONING All Informatio'n Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filIed in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
(volume,,&Location)
'
A. Has a Special Perm it/Varunce/Rndi ever been issued for/on the site?
/~~� v~� �~� �
N0 �� D�7K�� �� Y� ��
IF YES, date issued:. /
IF YES: Was the permit recorded at the Registry of Deeds?
NO D0m7 vu,
IF YES: enter Book Pogo and/or Documonc#� '
-
�� ��
B. Dues the site contain a bouuk, body of water or wetlands? NO �_��� DON'T KNOW �~� YES ��,
IF YES, has permit been nrneed to be obtained from the Conservation Commission?
Needs to be obtained �_� Obtained�~� on /—\ 'Oa�m Issued:
\,~/ ' � '
C. Do any signs exist on the property? ��� YES �~/ N0 t_�
'
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 0
'
|F YES, describe size, type and location: !
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre nris it part ofo common plan
that will disturb over 1 oono? YEG K ) � NO K )
_ ' _
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
' � a
__-...---City of Northampton Statu�ot P�rm�tt ;
1ldin 4 �
1
Cr�rbCmt�DfiyewayPermit
�yY� g De partment
1 ( Cn �12 Main Street SewertSepticAyailatstlfty
. . -
�. Room 100 W`6tbtjW'6I'Av. I bility
ry ^� No_rrinpton; MA 01060 TuvoSetsoStructuralPlans
`phone 41 -58711240 Fax 413-587-1272 P[ot.Site Plans �
Other Specify
APPLICATION TO C'ON. E-T;ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION'
1 Property Address: This section to be completed:by office
Lot' .Unit.
one., .' Overlay District.
Elm SL District CB District
SECTION 2-PROPERTY`OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of/Record: A
Name(Print) Current Mailing Address:
13 -5 8'y--g3tis
Telephone
Signature
2.2 Authorized Aqent:
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
. Building f ,75. �� _ (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=0 +2+3+4+5) Check Number >
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature: r
Building Commissioner/Inspector of Buildings- Date
243 ACREBROOK DR BP-2005-0684
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-359 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit# BP-2005-0684
Project# ]S-2005-0926
Est.Cost: $175.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 15028.20 Owner: MURPHY TIMOTHY&KATHRYN
Zoning:URA Applicant: MURPHY TIMOTHY & KATHRYN
AT: 243 ACRBBROOK DR
Applicant Address: Phone: Insurance:
243 ACREBROOK DR (413) 587-9375 (�
FLORENCEMA01062 ISSUED ON.12122104 0:00:00 -
TO-PERFORM THE FOLLOWING WORK:INSTALL WOODSTOVE
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: FinaWk
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI OF
ANY OF ITS RULES AND REGULATIONS. ;7 M
Certificate of Occupancy !,? Signature: /VUU
FeeTVpe: Receipt No: Date Paid: Check No: Amount:
Building 12/22/04 0:00:00 16$3 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo