35-059 (2) \D J
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g•CHAAIP�.
.(rZfg a Nart4aillptan
$ � �1'ilassachusctts
w i. DEPARTMENT OF BUILDF),, INSPECTIONS
INSPECTOR 212 Main Street * Municiptl Building
Nortli=pton,MA 01060
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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:,iso.r. The stale defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a one or wo jay _-
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 bui1 ing department for the City of Northampton wants-anyperson(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 r'.egulations. 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 p
location
5;5 ell e.- Z
k�o �oyE (rii of Pori lla11133 toll
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DEPARTME1fT OP DUILDC\1C INSPPCr101.'s
i -
212 Main Strcct ASunicipal DuIldin0
J Northampton, ATacs- 010GO
WORK-I Z'S CONIPEI>iSliTIO.T� D` SUPONC� ?.I'I"I�A.V1
i
%vILb a principal place of businessfresidence zt: — --
(phone-=)
(scr>~.t/ci ty/sZatcfa p)
do hereby certify, under the.pa_int and penalties of penury, --hai
{ O I am an employer providing the following!%i,orkcr5 c0lnocns-n:30n cove Inc for my
employccs %vorlong on this job:
iC1=sure Corr v) (''r olio: ?v=—.�-r) (_:pir`tior.DzL)
I am a sole proprietor, general eontraaor r homeowner c tie one) and hive hired
i the contractors lined below Tgbo have the `ollo,vi.oR worker's comoen_sation pokles:
I
ONamc of Con- Em or) (IRR rant.^- CompaP]}•/bout-i ��liltIl��r) r';J1r'JL3Q4 I�l1C)
i
i (Namc of C000mmor) (lnssranc Comoam-170um Numccr) (E%- mlion Daie)
I
(N me of Co=t-16;) (Laam ncc Comp.=y/Pot cy Namb,-J) (Expimaon Dam)
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(Iqz$c of Contractor) (Inrulan Compzay/Policy Nuu,Yr (Expo-,6on D=).
<naa :d3i�ocl 3c .ifncoczc_ti•w ncvtt�afonna�oc;_*in w.Il
I am-a sole proprietor and -have no one wor4dDg for me.
1 I am..a home o-,Vuer performing all the Nvork myself.
i
NOTE:plcsc be crosrt ri—-izij,bcmcmxn uto c=plcry pc;.a=to do - -•m-- c=,—.=on c fair work on c d.•cll_�of
ant mocz t�-^U roe ifs in -bcb the bomoowac r ada or oa the crv=&zpp rLm=--the an=,ox V=�r_!ly crcd_-td to tic
C=Vlcyc-s unP-e the�.a 1 ,_ea q,=(Gu15Z:31(5)�=ppliapca by a bommgac fc c 6c- -«pewit=y erfd=D=Lbc
Ic,PJ e, of u &-r dao Woke. pa Azf- '
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1 uodc:a d tha n ooyy of tbi.cat®mt m y bo foe---d.d rn the Dopusmmr of Indus-sicl Ac.�dar.�office of[ca+c.00e for th.
covczSe v=-!Gc=ioc cad(h=t L-ittae w sacurt:'00--v se tmdc=C:dc a 23A of MOL 152 na tee to the L--P=tioa of a mia�l pea+Jtia
000str..-iag oCa fiat of tip to S 1300.00.sadfor i�s-isosaoi orup to ooc y,s,d c%-;j p=.Y.ia is 6,fo=or.Ssnp Wort Ordc n d a
j fry oC S l 00.00 a d_y Lp.inst CD_-
i For�,r�•y1 u,e only .
PermJ(HL3IDbCS
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Man:—_ I-ot e - —
Si�atun of Lio=L-cc/Pcrmiu= _ e
SECTION 8-CONSTRUCTION SERVICES j
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
J2e ere 1�°ome rovementritrao" r ,_. Not Applicable ❑
Company Name Registration Num er
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION'`INSURANCE AFFIDAVIT(M.GL.c,152 §•25C(s))
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...... ❑
W
�V, W
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 bome 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 hirc 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
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SECTION 5-DESCRIPTION OF PROPOSED WORK{check all applicable)'
New House F_� Addition [] Replacement Windows Alteration(s) Roofing ❑
Or Doors 171
Accessory Bldg. ® Demolition ❑ New Signs [0] Decks [[] Siding[M] Other[a]
Brief Description of Proposed
Work: U/✓i1/5L( r /� �Tr7G-t' ��Ll>�NC;— O� 1p
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
m � U ;�.., ,9"'<aa ..-rte,':e �°^°C'1-�,.-,'. ,.
6a=#f Nevirousdr. n•' - ddi#w�to eis#ng:�iotSt.ng..=complet�.#he�a�Ceinrttig:
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, 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.
i
Prin ame
Signature of Owner/Agent Date
~
Section 4. ZONING All Informati6h 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 X
Frontage
Setbacks Front
Rear r-71
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bIdg&paved F-1
#of Parking Spaces
(volume,&Location)
A. Has Special Perm�/Varanoe/Findi ever been issued for/on the s�n?
' x�� x�� �
NO �� D�7K�W �� YES ��
IF YES, data issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO �_��
� uvm / mvuvv 0 .ES
IF YES: enter Book Page', and/or Document#|
��
B. Does the site contain a brook, body of water orwedands? NO �~� DON7KNOVV «~� YES
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tmbeobta[nsd �~� Qbta�med v�� Date
�_� �~� ' .
��
C. Do any signs exist unthe 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 x~~\ NO
'
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre ovis it part ofo common plan
that will disturb over 1acre? YES NO
|F YES,then o Northampton Storm Water Management Permit from the DPW is required.
---- ,,Northampton
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{ I.' S V ng Department
01� Main Street a
bom 100
r U U 2 3 204lorth ton; MA 01060 s
phone 413-587-1 40 Fax 413-587-1272
n -�� *, �- '!S .
APPLICATION 1?OC TER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: n to{hecompieted by office
� Thrs sectro
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ZOCIe Ive ,V
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SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
WICCIra" ►
Name(Print) Current Mailing Address:
,pf S�L--2SO�
_ jrjj0�/�r vim- Telephone
Signature
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 is ,(a)Building-Permit Fee
2. Electrical (ti)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) /JOP� °=— Check Number
This Section For O.fflcial Use Only
Date
Building Permit Number Issued:
Signature:
I
Building Commissioner/Inspector of Buildings- Date
File#BP-2006-0202
APPLICANT/CONTACT PERSON HUBBARD WILLIAM B&SANDRA S
ADDRESS/PHONE P O BOX 60166 FLORENCE (413)586-2508()
PROPERTY LOCATION 932 RYAN RD
MAP 35 PARCEL 059 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: ERECT 12 X 16 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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 mmission
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.
932 RYAN RD BP-2006-0202
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35-059 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0202
Project# JS-2006-0298
Est.Cost: $1100.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa.Al 66211.20 Owner. HUBBARD WILLIAM B&SANDRA S
zoning: SR Applicant: HUBBARD WILLIAM B & SANDRA S
AT. 932 RYAN RD
Applicant Address: Phone: Insurance:
P O BOX 60166 (413) 586-2508 ()
FLORENCEMA01062 ISSUED ON.813012005 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECT 12 X 16 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 Occupancy Signature:
FeeType: Date Paid: Amount:
Building 8/30/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo