35-060 (3) M
O�'SIiAMP�� .
' Z
1834ALItSS4t�t4
DEPARTMENT OF BUILDITIG INSPECTIONS /=
INSPECTOR '212 Main Street • Municipal Building
Nordiampton, MA 01060 .
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as his/her construction sups. ,, sor. T he state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,a dne or-two faamiTy
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-b-nil Ing department for Me 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-tome
Date-
Address of work
location
r
O�YIlJ..)•f p�O J.. _
U.If� L7f (��Ql"f1j3111�3fD11
A f - gl c3 inch nrclls'
DEPARiME14T OP DUILOD,,10 INSPECTION'S
j 212 Alain Street Municipal DmIding
i Northampton, ATass- 01060
woruccn.s Cow[PENSATION MSURA-NCE AFFU AV-1T
-- —•- -- (IiccnsxJpermiticc) -------- - ----- --- - -- ---- ---
%1,itb a principal placz of business residence at: - -
S� Qrrtilc�c 1c s� L s Air- (phone'') S'�6 8 W r-
(s =L'Cicy/S,=/ri0)
do hereby cerrifj under tl)c.pzins and penalties of penury, thai
j ( ) I am an employer providing the followin-,v.,ori:e>'s comocns-ntio, coverage for n)v
emplovees worbng on uus job:
iQ2nlr�c Com=-zN,) (Police:Number) (r:-pirz or.Du) '
i
( ) I am a sole proprietor, general contractor or homeowner (c c:e one) and have hired
I
the contractors L.- di below cvbo hive the following, worker's compen_,26on pokiest
i
(i+amc Oi Con(^Ci0') (111--u licc (Fi;J11d;0n D1lc)
j
(Nzmc Of CooTzczor) (lnssra.acm C.omam-RoUc; Nuns=r) ( xpim6on Date) -
(Name of Conmlma;) (I»u-alac=Comcazy/'POUC}" Nambu) (Expiraoa Dam)
i
(Name of Contramor) (Insurance Comcarly/Policy Numb=:r) (Expiration Datc).
(aaaca: noccl�'x�.ilacc�i w mc+s�jarocr3,=joa perwnaa&to.17
O I am-a -sole proprietor and have no one woridng for me.
( ) I am,a home o•voer performing all the work myself.
NOTE:plea be cwmrc ti` _jz:je bcc=O v=rs.to asplay peoas to tiz �-- c�.s.��a rgas—uric an.dJJ_-Z of
tux mat tbrn L---tits is inch the bomoowvC raid=cc oa the V-oua6 zppurtcn==theta c:ox C>.rlly CCc:d_-'cd io be
ersploycs uce.=the.Vrk=:0==p --+1m A=(GUI 51 n 1(5)1=gptica.600 by.bom—A-w,fc-be--a P=mh=Y e.-.dmoc Lb e
Icgsl Haase of—-:Ploy-<under dae Wock e,Compom.tioa Ace.
1 uadcsz+.nd d'A a copy of this car.cm1 may be foa-a•nrded to the pcpe tm�or Inh+xnn!AccdcalY OIL—of L--roc tb,
ee vm iretioa and lIu L-ilu•e to,CO=)C0%=Use rand=scc;tioa 23 A or m(IL 13-2 as ltd to the i asvioa of eimiaal pea-hie
eOn=ma of a lioe orup to SI}00.00 andfor 6=pr oc==orup w o=y=r e.od ctiu pen.t'um is t+c room ora Stop Work Ord=cad+
151=of S 100.00 z d'-y ap-iast M,_
For dgs.r�'�'-�u.c only
J l3crmi t)`ItSML 7
1 ' 1"C - iC,S�sc_^lPc rm i t t r� L,,Rce
G"-'l
SECTION 8-CONSTRUCTION SERVICES 71
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
'Re'rs`te l=Ca`rire=frri ioveineEatraEta q`° Not Applicable ❑
Company Name Registration Num er
JL
Address Expiration15ate
Telephone �G
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...... ❑
mY Offi-
elan
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 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
f
SECTION 5-DESCRIPTION OP PROPOSED WORK(check allayolicable}
New House Addition []:, Replacemen W iudews Alteration(s) Q Roofing Q
Or Doors 2
Accessory Bldg. ❑ Demolition ❑ New Signs (0] Decks (M Siding[p] Other fo]
Brief Description of Prop se
Work:-- -- v�--5i I (-E taJoe4_Y-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a4f WWI hdu s tans R��IC�1�LQt O EXCSfILiC�CIOCtS[FICl:COtEti3�������cT[�QYf�tC[Q:
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 CONT.RACTORAPPLIES 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 (�►i� S�i� as Ow Autho,rized ))
genf1jereby declare that the statements and information on the foregoing application are true and accurate,to the best of m "wl8age
lief.
Signed under the pains and penalties of perjury.
Print Name
e /o i4lG S
Si of O.nrlkqev Date
i
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
Side L: R ' 'L:.— R:I ^_
_`—
Rear
Building Height --
a
Bldg.Square Footage %
I
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume,&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 Q YES 0
IF YES: enter Book = Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DON'f KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained ® Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
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
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 r NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
E� 4
Building Department dI
212 Main Street
Room 100 er rreabI _ m
Northampton; MA 01060 Tub ets Str ctr+�� "�k
phone 413-587-1240 Fax 413-587-1272 PtatSi ` a y
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION!1 -SITE INFORMATION
,; This section to be completed bxolfce
1.1 Property Address:
-
.
Ma
Zone �� Overfag Dusfnct
EImS�District _ -� -.GB 17�str��t ;
-SECTION:2-PROPERTY OWNERSHIPIAUTHORIZED'AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
SI
Name(Print) Current Mailing Address:
67 7/2--
ur Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by enmit applicant
1. Building (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=(1 +2+3+4+5) Co 3 Check Number '7�
This Sectiow For Officiall Use Only
Date,
Building;Permit Number. v 6 -t Issued: L
Signature: r l U ?it J •-
Building Commissioner/Inspector of Buildings Date
922-RYAN RD BP-2006-0440
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35-060 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0440
Proiect# JS-2006-0643
Est.Cost: $6340.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sg. ft.): 50616.72 Owner: ADELMAN KAREN D&MARY CURTIN
Zoning: SR Applicant: John Corbett
AT: 922 RYAN RD
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:1012112005 0:00:00
TO PERFORM THE FOLLOWING WORK.-Replacement Windows
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 10/21/2005 0:00:00 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo