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DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR
"212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as i:is/her construction sup(.,. ,'s sor. T he state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or hvo fami1y__
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 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
- - understand the above.
(Ho a owner/residents ature requesting exemption
I will call to schedule all requ ed building inspections necessary for the building permit
issued to me.
Date
Address of work
location
R� ti� (riff �f {arfllaiil}�to)1 -
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DEPARTMENT OF DUILDrNG INSPEC71ONS -
212 Alain Strcct Municipal Budding
Northampton, Mass. 010GO
WOIUCCR'S CoNfP ;NSATTON MSURA_NCF Al FD)AVIT"
(li ccusx/perm�ttcc)
%Vith a prmcipal place of business/residencc at: --- --
(sue t fci t•Jlst=1:6 p)
do hereby terrify, under dic.pains -nd penalties of perjury, .hai
( ) I an an employer providing die followine''workcr's comocns� io, cove�s c or lay
emplovees ivorUng on tills job:
(I SU-T-n=Coc= v) (PCLIC: N'U= -r) -- (r:pirauon Dz1:_-)
( ) I am a sole proprietor, general contractor or homeowner (ci:cie one) 2-od have hired
the concractgrs listed below wbo have the folio%ving worker's pabcies:
(NIMc Oi Co„_^Cior) (Ir1R!ranc;. Cornpan1 -flPGUc'i NtuII1LC) (!'xpi lu^n Datc)
- (Name of ConcZaor) (nsl=cz Comoan`1pouc- N-umc^-r) (%xDiraiioa Date)
(Name of COUMLIOr) (Insu azc; Compan)-fPobc)- Numbzr) (Ir.xpira6on Dale)
(Name of Caotracior) (Insurance Comraay/PoEcy Numb r) (Expiraiioa Da c).
c`.cG.ifncoc--ia�•tn incu6c-inrocmi'ion p�•tn' w.11 Door-_+_o�)
O I am'a sole proprietor and have no one wor4.3ng for me.
( ) I am.a home owner performing all the work myself.
NOTE:piece>x ewltt tfi.,k{;]a hcmeo.�vc:-a_gyp C=Xplay Dccoai w 60 rCpZIr wroric oa.d%-U-'-Z Or
Oot morn th_a t .=t t is u$i6 the bomoawoc roido oc oa the U O,a ippurtCC--=theeo wr ax c-- -ly occcd-ni-tic
aiiplcr--u--' the-'Ov fs c=ap . ca pcz GL!52y=l S
t ( )}.a.pplicz,6oa bye 6omcoa-Oa fcr c Fi-c-r-v_-or pa=il n_y�id�tl:c
Icg�l etas a of ea-=ployx under don WocScola Compomatio¢Ad
14ndettaad tb-a Dopy of thi,mi.emeaa may ba roe-,.a,•d.d to the Dega.tm.w ar I-A—rid Aeedeatr'OM-of trr—roc th.
coverx�c va-iGt=iioa and aL.t C- a=ut
=-c to t `cO%crase undc loaioa 23A of MOL 151 can ltd to the i=ip-itioa of criminal pcaili,=
coa=Z7IIIg or t rmc OrUp W S I Jl 00-00 andIce aalauo®c=oCUp to ooe y,=d ci,-U pm.l'JO tO[!,,r0cm Of.Stop Wort Or Lad
tiro of S 100.00 a d y a&ai=tnc
pCTIDIf NtiIDtkl _
Lot
Signatiirc ofLia-ns— Crmiucc �� �� -- -j
SECTIONS CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9;Re isterecTHo`mefim "r"ovement:EontFactoN" _` Not Applicable ❑
Company Name Registration Num er --- —
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION'INSURANCE AFFIDAVIT-(M:G.L,c.152',§25CM)
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...... ❑
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,St d Local omng Laws ana-State of Massachusetts General Laws Annotated.
omeowner Signature
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check�all applicable)
New House ❑ Addition ❑: Replacement Windows Alteration(s) Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[[3] Other[O]
Brief Description of Proposed -
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
,.•; ..K A,..p-;.�.--..<,,.z.r .:, s*t°`.t-r.za�„c -`"n '.a."t...��� .t?�-: , --%srm-..
6 { tt ernr �roc�sean&&o iddf t6 ='0 extstt ct bo slr�c .comp ete>the oifQUr��c�g:
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 BUILDIMGPERMIT
1 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
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 pa[is and penalties of perjury.
Print Name
Signature of Owner/Agernt Date
.~
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Section 4. ZONING All Informatibil 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
Rear 6
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved F—f
#of Parking Spaces
(volume,&Loc ion)
A. Has a| Perm it/Vuriance/F ndi ever been bsuedfor/on the sha?
|
N ' 0 DON7KNOVV 0 YES 0 �
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO K ] DON7KNOW 0 YES
IF YES: enter Book and/or Document#
'
B. Does the site contain u brook, body of water orwetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has permit been urneed tobeobtained from the Conservation Commission?
'
Needs tobeobtaiomd �~� Obtm�ne� �~� Date
�~� �~� ' �
C. Do any signs exist on the propert �� ��y? 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 0 NO 0
IF YES, describe size, type and location:
E Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre orisd part ofa common plan
that will disturb over 1acre? YES K ) NO K �
~-� ! ~~/
|F YES,then o Northampton Storm Water Management Permit from the DPW isrequired.
n'
`6th of Nortt ampton
Building Department �► .t �w � « r
212--Alain Street sewer a tli ��'
Room 100 r�lftletF lafaf► ���
Northampton MA 01060 eS3r� rat ?Iakntt � �
y pp
413 $'1-124 Fax 413-587-1272 PIo te 'fa
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION'1 -SITE,INFORMATION
1.1 Property Address: Thrs section to be co[npleted`;byoff[ -
x .
�� Oueria
,:El SL District CB District
SECTION'2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
4 ( Z CAJ,1 IIIr�nE
Nam (Print) ` Current Mailing Address:
la (ii_� 14=7/�
Signat e Telep� hZ�ne
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 ✓ (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) Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
i
Building Commissioner/inspector of Buildings Date
File#BP-2005-1105
APPLICANT/CONTACT PERSON DING SOKPETH&SOPHAL
ADDRESS/PHONE 12 CAHILLANE TERR FLORENCE ()586-7112 Q
PROPERTY LOCATION 12 CAHILLANE TERR
MAP 35 PARCEL 096 001 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 8 X 10 SHED
New Construction
Non Structural interior renovations
Addition to Existing
AccessoKy 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
IN�FqIIMATION 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 Co on
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.
12 CAHILLANE TERR BP-2005-1105
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map•Block: 35-096 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2005-1105
Project# JS-2005-1500
Est. Cost: $300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sc. ft.): 9975.24 Owner: DING SOKPETH&SOPHAL
Zoning SR Applicant. DING SOKPETH & SOPHAL
AT.• 12 CAHILLANE TERR
Applicant Address: Phone: Insurance.
12 CAHILLANE TERR O 586-7112 O
FLORENCEMA01062 ISSUED ON:5119105 0:00.00
TO PERFORM THE FOLLOWING WORK.-ERECT 8 X 10 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 5/19/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo