35-072 (2) O�gHAMp�o
g� Gify of Nort4auipton z
� � �Tassachirsctts
m DEPARTMENT OF BUILDING INSPECTIONS /?
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sup,,;:-,• 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 hour), a rough buildine 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
ima
e
understand the above.
ome own r/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 ,
1
� � �1,If�T CZf r�Ltz"���c1771�J�C1iI
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m ll 'PARI' ENT of EUILBDJ G INSPECTIONS
212 Main Street ' Municipal Building
N"orthatmpton, class. 01060
WORICER'S COMTENI SATION INSUIZANCE AFITDANr1.T
v"I'kh a principal place of busiress/r sieenc a!*
do hereby ccrLiLy, un:I r the pans .hnd pen:hies o pc:rjilry, :i1a:
an employer providng the ollo,v;nc, .orr_ers compensation covcravc 'or my
employce.s Nvorlarlg on this job:
(Insirana Compam') c icr N;tmbu) ---- (F--,-Gir:ation Date)
I `ci a sole proonetor, general horntov ne: (cLc!e onel and t:z.-e nire(-1
the- contractors listed bei0 ;;l]0 ill r';, the i041 .y;r vJOr rte S comn)tns-'iorl C4i S:
(Name of Contractor) Datc)
(N ame of ConT<cto:-) Cc)m-_.v�Pole, \i s�r, ' Date)
(Name of Contnclor) (Ins-dr-mcz t-t m—"Iau"i Ohc- Iv11JIlt7_I) . (-.l"".:,-;;i: S Dat'c)
-- r� (f
(Name of of Contractor) (Ias-u .nc� Cei. - .y,h oLicy Ivu.mb�)
( I ZU11 i. ;;Ole prapnc""); a-'Id have 110 onc for II?
111 < home Owvn-'' all iI' iii'r S 'Ih
NO"rIi:plc sc be Aw:c that cr:-pair
not uxvc til n ttu'oc uui,I it tc•L rc:=cr a;'`"t
—ployc�3 ur16cr t}r wc:trr s cc x•—>e:im r ((7311152-s--1(5)1,-,:1:__'ica by a ho aro«-cr for a Gccu a p=r.-.:i:
Icgxl rtatus of an csployx uou' tLo Workors aL,xry.lian AcL
1 undcrsta.nd tilt a c<r y of tbi- ctatci.cct may bo fawnr'J to t' of Ir dustrml Mid-r:Y Ctucw of L r.u.a-4 for Ul
covcmgc varificatioa and that f_ilurc tot uc cw,-mg.,ut 3: cC,iai 25A of MOM 152 czn lead to the mposition o,'"r i 1 pctLl1%:cs
to S 1 00. a;t'.'rr ir:ari7.xur'c:-'of to nr.: zar r.r.1 civil,>rultia in do fcmn Of a Str,,` nz.Ch:an l a
coasis2ing of a fur of up S 00 ::? }
fr c oCS100.00 a day agr-in:A m:. -
For d'A-'s UI—Oj t„�«,ly j
4�Lx X-e�- -
--
.
I aturc()f:.iccu cc/I'crm ll.tre "''
S�CTON 8 ;:CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Reg s e e m rr r ement 'ontracto " Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SEC 10 A WORKERS' COMPENSATION 11, WNC&AFFIDAVIT(M G:L.-.c. 152,>§ 25C(6p
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...... ❑
F 11
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"homeoNvner" 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 resu!ting 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, St nd Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION - R PTfOt Of PFtOPOSELMORK ch"ck� it`a licabie
.�...w^&34}'z.. .. "YxWx^**.fi^
X.
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ .
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding Other [ ]
Brief Description of Proposed Work: tZae Q
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0 • Sheet D
a fiN: oe"nc�`ora:�dition`to exstingh uo srng co"�p e..flifl;lo..win :
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. Mascheck 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
1lYxER�L3TL�RIZATi0N; TO S;E COtVIPLEXT,ED WHEN
OWNEFS�A E O CONYR CTOR APR0 EST FOR BUt°LDING PERhAIT
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.
Print N e
Sign e f Owner/ ent Date
t
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF 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:
Rear
Building Height
Bldg.Square Footage %
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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the 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 _
No
IF-YES, describe size, type and location:
City of Northampton
--- Building Department
212 Main Street
Room 100
rthampton, MA 01060
es -587.1240 Fax 413-587.1272
RUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
$,EC'T10N 1 -SITE INFORMATION ,. .
This sectio'' ti° "omp etclbyaff�c
1.1 Property Address:
Map L
ED
�i// �Zon "� �• Ov rla �stric�: � � �`
I /0 peEnC E.- x"g'
EIm St�District �;�-� � G$DDS r�ct�� �' •-"`
SECTION 2 - PROPERTY OWIN RSHIP/AUTHORIZED AGENT
2.1 Owner of Record: r'
Name(Pn t Current Mailing d ress: ✓
Telephone
Signa4x _
2,2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone _.
SECTION.3 - ESTIMATED CONSTRl1CTION.CQ"STS
Item Estimated Cost (Dollars) to be Official Use Oly
completed by ermit applicant
1. Building c! (a) Building Permit Fee
2. Elec.rical (b) L 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
This Section For Official Use On YL
Building Permit Number: - r Date Issued:
Signature:
of Buildings Date
Building Commissioner/lnspector.
T
File#BP-2004-0103
APPLICANT/CONTACT PERSON KABAT HENRY F&JANE H
ADDRESS/PHONE 884 RYAN RD (413)584-1565 ()
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
Typeof Construction: INSTALL
New Construction 1320 -_
Non Structural interior renovations
Addition to Existiniz
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Commission
Signature of Building icial V 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.
BP-2004-0103
G I IS#: COMMONWEALTH OF MASSACHUSETTS
`$ R CITY OF NORTHAMPTON
. -1�
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0103
Project# JS-2004-0167
Est.Cost: $250.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(s4.ft.): 19994.04 Owner: KABAT HENRY F&JANE H
Zoning'SR AQplicant: KABAT HENRY F &JANE H
AT. 884 RYAN RD
Applicant Address: Phone: Insurance:
884 RYAN RD (413) 584-1565 O
FLORENCEMA01062 ISSUED ON.814103 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ENTRANCE DOOR IN GARAGE
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 Occupang Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 8/4/03 0:00:00 4176 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo