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DEPARTMENT OF BUILDDtG INSPECTIONS -
'212 Main Street • Municipal Building
INSPECTOR
Northamptan, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as l.is/her construction sups-visor. The state defines "Homeowner" as, " ierson(s)
who owns a parcel on which he/she resides or intends to be,a one or""two fame y -
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 oven 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
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��tLA}rnro -
i
R� (riff >?fTarflJal)1pfoli _
A- ! .61 a7:itcharclle' -
o DEPARTMENT OP DUIL.DD\IG INSPPCTIOI,,s
212 Train Street ' Municipal Dudding
Throrthampton, Mass. 01060
VV0r 10EIZ'S CON'ff T`.NSATIO.N IMSURA1rCE A 17FI D vr
I, All Star Insulation & Siding Co., Inc.
j (li ccvszlperm�tttx)
v.Ith a principal place of businessfresidenc.e at: - - --
i
56 Franklin Street_- Easthampton, MA 01027 (phone=)413-527-0044
(sa>.:t/c'i ty/slate/Di p)
do hereby certify, under the pains and penalties of per* .-, l?�1
(X) I am an employer providing, file follow;nt %vorker'5 comocnsZdo cove Ike for in)
etuplovices v-,orUng on ribs job:
,Mw.m=Coq -M) (PcLic. NL-.—r) ( :-pir-auor, Dom)
O I am a sole proprietor, general contractor or homeowner (cu cie one) and have hired
the contractors listed below vgbo have the folio%viag worker's c000en_pdon pc!icies:
j
(Nam-, of Con, cto-) (lnRranc;_ Company/1'obc; '�'LUnLcr) (E>:�i,�ron l�atc)
(Namt of Coolraaor) (Uisaraacc Comna.n".1pok \uzncsr) (Expir-66n Date)
(Name of Connacto;) (LaRuance Compa.ny/PoL•c)' Nusbc_r) (Expiration Date)
(Name of Contractor) (Lasurancz- Compaay/PoEcy 1`tumbcr) ( xpp-,600 Date).
(aaa.c�1 a6di-�oc=1 dcC,tr acCG-a11 to mCtt�inform&zioo PCruda ac b.11 ooCS---C-O.�)
{ ) I am;a sole proprietor and have no one wor i-og for me.
( } I am,a home owner performing all the work myself.
NOTE:pl^,-be cwwc rfi.. .jjj. _bo cmPloy Pcwri LO o .:ejoo c repair�0ri:av L d—LL-Mg of
ant ranee tb_o t Lmi�is te$ic.t+ the bomoowncr read,,or oa the aaim,S z,purtcw-=tbccn :t ox Ca -Uy need-cd re be
cavlor—11 'e the.=kcrz e==P e---,oo Art(GUI 5L=l(5)�_pptinbon by a bomooava far a Gem_or pcmn cry e�rd—tbe
IeSa rtzyi or et m,loyar under den W.,;c- r CompomaL ArL
I undcstaad tba a oopy ortbia mt<m—a may b-r.,---ded to Lb.Dc ,—t A—a.. 'OIL-of 6u—roe Lb.
oove�Lse�eriGatioa o_�d th:1 L•ilLac to soasrc foverysa Lrodc soa�oa 23 A o(hlot 152 an le.d Lo the iiw o(cimins!pecuL.ia
mmi.ss�of a riac of�to 5100.00 andlor�iyo°mey o(up to ooc yvr e.od aril pmaltia is Px form of.Surp Worl:Order and.
rim 0(5 100.00 a day LPIMI tix
For&, --'1 u, only
1 1'CTmll Nt1IDt)CS _
-- �� 1`,13P: Lot•° �.
Si 'Iatult of Lia=Lxx/Pcrmiucc
SECTION -CONSTRUCTION SERVICES'
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
._ Sri -rte : d a
tx�emen' oi��rac�oc„ � k ,,r,.�, �, Not Applicable ❑
All Star Insulation & Siding Co., Inc.
Company Name Registation Num er —�-
56 Franklin Street L-Q. D�Q,---
Address Expiration Date
Easthanpton, MA 01027 Telephone 413-527-0044
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GIL. .452,,§',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....... lil, No...... ❑
Al
j
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 hue 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-vear 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,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
r
i
SECTION 5 DESCRIPTIONOF:PROPOSED'WORK(check all applicable)
a
New House ❑ Addition F7 Replacement Windows Alteration(s) ( Roofing E]
Or Doors D T
Accessory Bldg. ❑ Demolition ❑ New Signs [n] Decks [M Siding[0] Other[E3]
Brief Description of Proposed
Work: Q I;1 (`a
Alteration of existing bedroom Yes No ding new bedroom s No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
��yYa-'��.r ia�� •„•—'-�h`—su��”' �S:e_�, ��'�=a'�._
$a.1
VW:ouse>ap-3-15RO#io fc ex><st�ng iouslncl. ompiete;the" o[louxlnct:
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 TORE COMPLETED WHEN
OWNERS AGENT.ORtONTRAGTOkAPPLIES 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
I All Star Insulation & Siding Co Inc.' 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. '
__ Ed Losacana. (fnmeY/n__11 runt
Print Name 1
l�
Sign-ure of ner/Agent Date
� r
Section 4. ZONING All Informat-j6h 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 L:I ' R:' ' L:I R:I
Rear L
Building Height ' -I
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved
parking).
#of Parking Spaces
Fill:
(volume 8c Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:
—
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book ( Page' 1 and/or Document#!
i
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued: I
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO 0
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 0 r NO l
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton �l P
Building Department
212 Main Street we G 4 =
Room 100 r a `
- Northampton; MA 01060 r
phone 413-587-1240' Fax 413-587-1272 °
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
k �This section to be cotnpieted office t �
1.1 Property Address:
1 Ma a x ` Lot
MIN.?
Untt
SECTION.2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
All Star Insulation & Siding Co., Inc 56 Franklin Street - Eastha yton. MA 01027
Name(Print) Current Mailing Address:
413-527-0044
Signature Telephone
SECTION 3-'ESTIMATED-CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical ;ME I.stimated 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 Q LO
This'Section For'Ofricial'Use Onl
': Date
Building Permit Number. Issued:
Signature: '
i
Building Commissionerlinspectorof Buildings Date
36 PENCASAL DR BP-2007-0594
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-287 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-2007-0594
Project# JS-2007-000880
Est. Cost: $8953.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: All Star Insulation & Siding Co Inc 101858
Lot Size(sq.ft.): 11369.16 Owner: Northampton Housing Authority
Zoning: URA Applicant: All Star Insulation & Siding Co Inc
AT. 36 PENCASAL DR
Applicant Address: Phone: Insurance:
56 Franklin Street (413) 527-0044 Workers
Compensation
EASTHAMPTONMA01027 ISSUED ON:1112912006 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 11/29/2006 0:00:00 $25.0033806
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo