29-256 (2) M
¢CttAP1P�.
�118358C1'liStttB n -
Wn
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
North unpton, MA 01060 s
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to
act as has/her construction super v 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 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
O
L7f �\T 11 011
By E gZ435 nchncclla' —
DEPNtT'MENT OP ➢UILDrNC fNSPPGTiONS
�s V1 212 Alain Strect Municipal BUIldin�
Northampton, ATass. O]OGO
- WOMCCR'S COiYTENSATTON CgSURANCF A17FM AVIT-
\Vith a principal place of business/residence at:
(slzruc;ty%sta.tt!zi p)
do hereby certify, under U,)c-pa-ins and pe1121tieS of perlU-ry --hat
4111*1 am an employer providing thc. followinL %vorke>✓s compcasadon cove gc (or in)
employces worlong on this job:
y � �
(Instil'�c Conr c.) (Polio: Ku--arr_r) (�:-pirztim Dom)
( ) I am a sole proprietor, general contractor or homeow-cer (c cie one) and hive hired
the cono-aInors listed below wl;o have the following worke>'s comoen_stion policies:
0+IIII7: Oi COn= CiOr) (1[1Rrai1C Colnpasl}'��GUCi ?�rUQ1LC:) mwjon Ditc)
(Name of Coomaor) (Ins lance- Comoan}•ipoUc Nuzacrr) Date)
(Name of Conrad ) (Lau-an= Comp-=3-/PoUq- 1Nusbu) (Expimdoo Datc)
(Name of Cootraaar) (Insuran(-- Compauy/Policy Numb-J) (Expirtion Daft).
(nbadl d'i ocsl cSca,itncc v to ctcudc iarorrat�oo pcstniaias to.11
( ) I am a sole proprietor and have no one wor-;dog for me.
( } I am.a home owoer performing all t-be work myself.
NOTE:pl�se be ewire Le Ui3c hemew.o=.ate cmploy pq=%.C,=to L4" •' •� cam--rjoo rgair work on a d%,ei-Z of
txx most th a tEroc tmitr is Mich the bomoowncr rcida a oa the p ottpca zpptsttcc• the rn r ox smelly oecrdacd to I-
ctployea ttndc the t.xi -.,,�An(GLp SZss l(5)} apptintioa by a 6omooava for_Ge m or pewit ciy a�beoa the
j Ic•�ti cta----of ea eploy c under d-W«ir_la Coo>pamatio ^eL -
I—Z--d that a oopy or thin c__= =may be roe-+.nrded to the Dop�orindur-rw A—dectf CHLoo or Ir-+c•ooe roc the
ooYarx£c rc c=ioo nad th1 LALm to somrc wvcrnse under ulc ioa 25 of hiOL 152 an lad to the i osiiioa of eimiat!Prntltio
n^- of a riac or up to S 1}oo.00�rzior of up to occ yur=d cNil pm,.tia in 6c focm of a Stop Wort;Ordcz and a
f=0tS100.00.d_y tpictt me
Fos dcp.rtm �1 u,c ocJy
.�
Pc-mtI Numt>cr
1,43p" —_ [,oI a �.
S'!�-Z�um of LicrosrsJPc ucc tt3Le -- -) F=
s ,
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. �s �1 Not Applicable ❑
Name of License Holder
�j License Number _
PL
Address Expiration Date +
Signature Telephone
Not Applicable _❑
Company Name Registration Numbe
AddreExpiration Date
s �! /�
/� k) Telephone
SECTION 110-WORKERS'COMPENSATION INSURANCEAFFIDAVIT•(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 buildingoermit.
Signed Affidavit Attached Yes....... No...... ❑
TISm
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 he/she shall be
responsible for all such work performed under the buildine 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
s
..
SECTION 5--DESCRIPTION OF PROPOSED WORK(check all applicable
New House F� Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding 19-11f Other[p]
Brief Description of Proposed f^
Work:_ 4 57`i� r1 ����'� 3/,0/ A.)
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa if Ne toas�and or t, rtion;to_ex>s#ina:houslhi_ rrrMMIR � 641G Og:
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:-.OWNERAUTHORIZATION-;TO,BE'COMPLETED`.WHEN
OWNERS.AGENT OR-CONTRACTOR•APPLIES' OR-B�JILDING PERMIT
I,
1,5 !4 as Owner of the subject
property
hereby authorize Z_ IZ A<":y
to my half, i a authorize by this building permit application.
,.
Signature of Owner Date ej d
L /J �"���� as 0_qw/Authorized
Agent hereby declare that the statements and inforrhation 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
Na 7
Signature of Oow&,WAgent Date
wp
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
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
° *
`
�
A. Has a Special Perm it/Vuriance/F ever been issued for/on the site?
NO 0 DON7KNOW 0 YES 0
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
'
NO K ) DONT KNOW 0 YES
IF YES: enter Book Page, and/or Document#|
'
�� ��
B. Does the site contain abrook, body ufm/atarurwetlands? NO ��'�� DONTKN8VV �~� YES �~�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �� Obtained �� �� |��'
x_� \~� '
C. Do any signs exist on the pvoparty �� ��� YES �~� NO �^� ~
IF YES, describe type. ' �
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre nrioit part nfa common plan
that will disturb over acre? YES W NO ����
��
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
, t
NWA
Cit of Northampton
� £'`r
_. --°, Vding Department ~g
12 Main Street
Room 100
Nb8. ampton, MA 01060
tt11 ,
�q 2 pl�914 41�, -�` 7,-1240 Fax 413-587-1272 d �
-^,,n
tPP +GAT10f�tfi0 1 TRUCb ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION-11 -SITE"INFORMATION-
This section to be:completed by office
1.1 Property Address: w
lo/ ®U L .l.b 0�d D Map Urut
�.
Zone£ k Ove�Fa�Dfsfnct{
:EI�'i�t..T3tstr►ct 'a _ . fTH7DlStrlGt „_ -
SECTION'2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Re ord. '
Nam C' d A.Z�=AArr, G
M
Teleph �r
ignature
2.2 Authorized Agent: .%
Nance(Print) +1 Current Mailing Addre s: ?
Signature Telephone
SECTION-3 ESTIMATED CONSTRUCTIOWCOSTS-
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building Q a =(a)Building Permit Fee
2. Electrical (b)Estimated Total Cost,of`
Construction from 6.
3. Plumbing v^ Building Permit Fee:
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Al ' '(b c °�' Check Number
This Section For Official Use Only
-Date
Building Permit Number. Issued:
Signature:
Building Commissioner/inspector of Buildings Date
� *tr
BP-2006-1423
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2006-1423
Project# JS-2006-2089
Est.Cost: $4500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq.ft.): 15202.44 Owner: ALDRICH DALE&JAOUELINE
Zoning.URA Applicant: B & R Siding
AT. 101 OVERLOOK DR
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTON MA01060 ISSUED ON:612812006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING
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 6/28/2006 0:00:00 $25.0020424
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo