35-072 O¢-(fiAMp�O
a
� - 8 �GlassRC3�scsctfs
DEPARTMENT OF BUILDINIG INSPECTIONS
INSPECTOR 212 Main Street • Muuicip d Building S`
Northwnpton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction super .."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 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 buil mg department for the City of Northampton wants-any person(s)-whd-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),
s_onotube 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 occuvancv
until the work can be the work can be ins ected.
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
L understand the above.
(Aouie ownc.-/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
r
f #
I �
DEPARTMEI-rr OP BUILDr)\G INSPPCr10t.S
212 Main SLrcct Municipal Building
i NorLhampton, Mass. 01060
(�r��/�^T) r �7 ,
`�ORIG:- R S COwfPENSATTON GNSU A..NCE 1.1'1'JJJIIATj-
j ,
(li ccnsxJpermi tfcc)
�ViLh a principal place of businessfresidence at: - ---
(stn�t/ci ty/a2ltla p)
do hereby certify, under Llie.p?-ins :md penalties of perjury, hai
{ ( ) I am an employer providing the followir. !worker's cotnocnsabon coverv�e for u1ti
emplovecs worong on this job:
i
i (Lasusan= Comr-azy) (Poiic:?-L_a cr) -- (",piratior,D2i)
O I am a sole proprietor, general contractor or homeoWMer (c c:e one) a-nd have hired
i [he coon-actor's listed below who have the fold %inQ worker's cot nep_taaon pakies:
i
(1+.^-111: Oi CO�!�?CiOr) (In2r-anc:,:Cotnpan}•i:'cuc,- }�1LII1Lt:) �':�Iluuon D.ltc)
(Name of Concaaor) Compan}•:Polio; Numcsr) Date)
(Name of Conn maz ) (Insurance Compmy/Poucy Nz=bci) Fl_xpim6as Daic)
i
(Namc of Coatractar) (Insurance Comp
pan /Policy Numb r) (E1pirr6oa Da1c).
(alS1L1 sd3i�ocil deC,if ocoe.�-ti-w mc?u�iaforty�oc,—lci^_6 to.1I ccc-_c_.o=) - -
>�I am'a sole pFoprietor and have no one woridDg for me.
I ( ) I am..a home owner perforTaing all the work myself.
NOTE:plesc be ewzR t** c bcmca_,e s to etrploy p,=w rid �^ cis c,ao c rgair woric oa.d-U[ o of
got azoce tiv lr' _tests in Itch the bom owoc r=ed. c oo the Crvuzda zp ptzrtca_.^_.tbeeo c c Do(C=c'.11y oc�d.--cd to be
c-Pic)—unG. thew �a=p="':ca Aa(GO 52-=1(5)1=r^ptio.000 try a boa=a=fe-!ice-oc pe-mit M=T c idc�oc d-
l—p!cunu of ea e-tployo udder dyo WoA e.Compoo�.y;»a AeL '
I
I—d---d tb-a Dopy or thi,msea=o y bo roc�to the pcponmcrd or office or I--roc th.
—verxse vc-iretioa and t1u L-iltac to savvrc covcrnS-tmdc==Goa 25A of).((DL 152 ten lcd to the i=P=itioa Of mina!P`W`
env:i of a[wc or up in S 1-500.00 armor 6=pr6cnic=of up to Doc)r_r cod civil pc oLrj=is tt>c form of a Slop Wars;Ordc and a
f=of S 100-00 t dry cptinst ELY—
.. For dq.ra.�•t use duty
9j E
� PcfmSt l�t1IDt� —
Sif,--w c or iC lPcrtnittcc e
SECTION 8-CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
7
Name of License Holder:.- �t be r� 1 n Z of �, -.�? & 063s
License Nu er
/ 0
Address Expira on bat
Signature Telephone
9:Re'istered Home:"tnt"'raveittec►t Co�itraEtor. . - Not Applicable ❑
Company Name Registratio i --
Qz
Address 6 -;�%z Expiration to
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.-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....... No...... ❑
Xc
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
r
j
SECTION 5 DESCRIPTION OF PROPOSED WORK(check-all applicable?
New House ❑ Addition ED Replacement Windows Alteration(s) Q Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding>lf Other[0]
Brief De 'ption of Proposeld
Work: +P. p� q
Alteration of existing bedroom Yes No Adding new bedroom Yes , No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa fi l *Ruse an ,x c'di#ia ta�ex s i i fiausl u:eo p of fi fatfii t :
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-`OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENTOR CONTRACTOR APPLIES 0ORA31UILDING..PERMIT
I, fin_�^ � � as Owner of the subject
property /
hereby authorize �5 e r2� n o Z
to act on my behalf,in all matters relative to work authorized by this building permit ap ication.
Signature of Owner Date
ZJ�r 14 ,(Z04 as Owner/Authorized
Agent hereby declare that the statements and inform tion on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury. 1
Print Name
/ZoZT-
Signature of Owner/Agent D e
j_
Section 4. ZONING All Informatibti 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 t
Frontage — Z�F'
Setbacks Front
Side L: R:�
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved
azkin
#of Parking Spaces
Fill: _
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Re istry of Deeds?
NO Q DON'T KNOW YES Q
IF YES: enter Book Page, and/or Document#,
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW YES
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 Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,e5cavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O ,. NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Nortoampton
�- Building Departmentt �� �V F
?' r� Main Street
l �6
Room 100erely
Not ampton, MA 01060 at r c€trafPtar � f � .4
_ SEP 2 P 41'3-5 '7-1240 Fax 413-587-1272 atttn�
iA
P-PPEICIA IT QMSTH,J TRU!T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
7_.__5r sn--
SECTION 1 -SITE INFORMATION
o ice
1.1 Property Address: This section to be completed by ff
4 �•� of�. �o ti wNfaP L'"0 Untt
/ ,f -
�!o r,e r� �� / ,% Zone Overlay Distract
n`St Dlstrict GB Distract
SECTION;2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: J� y�
e rL-r- 1 /�Q rTL�� �v ��t i� [7 i Y' //) Y e-
Name(Print) � Current Mail' g ddress:
Telephone
Signature
2.2 Authorized Agent:
Name(Prin), Current Mai!!Kg/Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
c m leted by ermit applicant
1. Building Af U� r (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing -Building Permit Fee:
4. Mechanical(nVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section'For Official Use Only
Date
Building Permit Number. Issued:
Signature:
i
Building Commissioner/inspector of Buildings Date
File#BP-2006-0314
APPLICANT/CONTACT PERSON ROBERT BENOIT JR
ADDRESS/PHONE P O BOX 701 HATFIELD (413)247-9927()
PROPERTY LOCATION 884 RYAN RD
MAP 35 PARCEL 072 001 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
Tyueof Construction: REPAIR ROOFING/SIDING FROM TREE DAMAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 088335
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INYF9161ATION 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 C ssion
9 2/ J-��
Signature of Building Official D to
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.
884 RYAN RD BP-2006-0314
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-072 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0314
Project# JS-2006-0460
Est. Cost: $12000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ROBERT BENOIT JR 088335
Lot Size(sq.ft.): 19994.04 Owner: KABAT HENRY F&JANE H
Zoning: SR Applicant: ROBERT BENOIT JR
AT. 884 RYAN RD
Applicant Address: Phone: Insurance:
P O BOX 701 (413) 247-9927-0
HATFIELDMA01038 ISSUED ON:912112005 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR ROOFING/SIDING FROM TREE
DAMAGE
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 9/21/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo