29-081 (3) o
CIO
ffs , x 3(
Gl-
o
--d
0
0
o
-f--
o -- d
00 4, Jp
D
EE
r xw-f °
00
v
14 8146 o
�. .i
CY 12 �
iv
0
o�
Qlc
Lo
r9c x,ai
o
0
0
� U
v
�gttAMp�,
O O
Clitp of Xort4ainpton � z
�dbSAChlTbttlb I� -
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street * Municipal Building
NorthwnPum, MA 01060
rr
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/herconstruction suh,-: , 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 backE),
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 --7-
I,
:D6 P, / �/'�/������ 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
location .d/ ��'�?��.�-�'�'�� ._/ '/L)L%
al-111allip I Lill
NT OF PMIDPI (;
212 Main Street Municipal BmY,illlj'
NorLliamptoii, Mass. 010(e)0
COMPT"jN'SATION INSUBANCY AUVIDAN"IT
t I I t
o C,I'z' CCi
1 21:1 the I I o v" my
cl"Iplu".C"."' "vui �mg' onl liIIS
a p! oi,
I i .
th", Coll,mctol-.'; kste�' 'havc th'� fbil
11�e
A'�
Harzct
A1_( C",
,a atc)
mnc
Da�c)
'1'�)l :-a'
14
gal'tatuc of an 10y m,
-yy of f"'11'o
COVCTI�:c VC:I fic-n I;c'O r-ni"01!(f-I I urc 1c) -curc COIrTrg'�III x':"I M(-1,152 ctr,I,
it ICY�tr4;a:(I:l'::��1t r'.�.i�
-1"ItIllf,
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not �A+pplicable ❑
Name of License Holder : �rI��7/9•f%• ��w�h/( �p o'IbE.�C���. (..V
T ��� License Number
/8 1 Tcrra.c a 836 A/a/n r Cr
A r ss de�e A��/&Aj MA 0/330 Expiration Date/3�o3<r•Ro,D��. 1
torC/7EC, A _ 747/b
Signature Telephone
9 fReg(stered Home Improvement"Cornraetor ,_Q,', ; .1 „ a* F Not Applicable El
Company Name Registration Number
1% M.C;h OA� Qox 38'S 7/w to if
Address q Expir�te
IA MLLE` /T 4103/ Telephone(#/3)
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.......0 No...... ❑
. as
ap
s
1 � m04, WneHE empM
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 buildinL, 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 fcr which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 ;iLiability of Employers to
Employees for injuries not resulting in Death) of the Massachusctls 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 d Local Zoning and State of Massachusetts General Laws Annotated.
A
Homeowner Signature ` _
a
SECTION 5= DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] DeoR's [ ] Siding [ ] Other`
Brief Description of Proposed Work: POOL _-
Alteration of existing bedroom Yes _ No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes XNo
Plans Attached Roll ❑ • Sheet Ci
6a;lf`New house"` and or°addition to existing housing, con!pletethe.followin>Y:
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 construct!on. 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
I. 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 Q��� t_1 .•_-__�!!'/1IL�_ � __ _--_-__ __ to as; or.
- - -.
my behalf, in all matters relative tc ork .:rjthorized by llvc, Duilding permit application.
Signature ii Owner Date
�
/ i4/'�SF1_.� _. /I�• d�
hereby declare that the statements and information on the forego g application are true and accurai to The best of my
knowledge and belief.
Signed under the pains and penalties of perjury AZV
Pri�ameA'
hurl4k
Signatur of Owner/Agent T Date
a °I
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: .�2a" 1�
Rear
/°
Building Height
Bldg. Square Footage 13 7 6 % / �p
Open Space Footage % o
Lot area minus bldg&paved Q
parking)
#of Parking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 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 (-_main a brook, body of water or wetlands? NO _X_ bON'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. re there any proposed changes to or additions of signs intended for the property ?YES
Noy
IF YES, describe size, type and
• �sir
City of Northampton Statusof`Permil Y
Building Department Cdrb,GUt/D ve
212 Main Street Sew r Sep re flab
v � a
Room 100 Water/WeI 'vaf t "
Northampton, MA 01 060 Twa Sets of�Str 'e f an- _ �x�
phone 413-587-1240 Fax 413-5871272 P a ,
Other-Specify '
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
11 Pro?rt Y Address: This section to be completed,by office
f - - - — a.
79 Map Lot Unit
Zonq Overlay District'
Elm St. District_—_ CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
_1WAV.6677-11 M�9/►%sF�E[.�D ---,3� ��rc�rook �r., �/ar��/'►tR
O/o6�Name(Print) Cur en rd
Signature
2.2 Authorized Agent:
DiV (R -�.- J�'1AN,S /L�'L, --------- l�C�!e B�2o�lC e o, %cE Rif
Name(` int) urrerMaili �,. �adress. - -
O/G1G�,
Signature �-,I„,r �;.
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit apoli,ant
F3ulding
0 (a) Building Permit Fee
-Total Cost of
from 6)
3 Plumbing Building Permit Fee
5. Flit: nrotect,u1
�.�le�h w nUer
�> Total - ;l �_�_ ��. , ��-- ,:FAQ 0,�— -- ---� _ —
This Section For Official Use Onl
Building Permit Number:_-& -?�� Date -------
Signature:
L-- Building Commissioner/inspector of Buildings Gate
File#BP-2003-0751
APPLICANT/CONTACT PERSON MANSFIELD JOHN EDWARD&MARGAR
ADDRESS/PHONE 37 ACREBROOK DR (413)584-5091 Q
PROPERTY LOCATION 37 ACREBROOK DR
MAP 29 PARCEL 081 001 ZONE URA/WSP
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: CONSTRUCT 18 X 36 INGROUND POOL
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 FOLLOWING 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 S et Commission
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.
BP-2003-0751
GIs#: COMMONWEALTH OF MASSACHUSETTS
tAWA?**f CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0751
Project# JS-2003-1231
Est. Cost: $5800.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg ft.): 15942.96 Owner: MANSFIELD JOHN EDWARD&MARGAR
Zoninp,:URA/WSP Applicant: MANSFIELD JOHN EDWARD & MARGAR
AT. 37 ACREBROOK DR
Applicant Address: Phone: Insurance:
37 ACREBROOK DR (413) 584-5091 (�
FLORENCEMA01062 ISSUED ON:3121103 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 18 X 36 INGROUND POOL
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: Receipt No: Date Paid: Check No: Amount:
Building 3/21/03 0:00:00 417 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo