29-062 .Nft
Crity of Nort4ampton z I y
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction sups:. 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 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 proXct until such time as the proper permits and inspections are
made
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
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(1-iftt of �K>_ rfljalttpfclit
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DLPARTME?vii 01' BUILDING INSPECTIONS
212 Main Street ' Municipal Builcling
Northampton, Mass. 01060
WOP CE,R'S COMPENSATION INSUIZANCE AFI)AVIT
A
vnth a principal place. of bus1FcSsJrC`;id1-11cc t:
(StTc,-Ucir;i'; <�p)
C{O L1CI"eU}' CCrt.LI}', ua:'c1" 1110 pc,M-s iiCl pCil it, of pof3ury,
K I am au employer providing the fol{ov.,mL' '.':ol'r,Cr`5 COIIIPC;]Sat10I] COVCr<::.0 ror my
employees wor-king on this job: v
Zr�S ,
(Lam=ce Corn try) (e c;Ni nnbcr) ('ExTimiion Date)
( j I am a sole proprietor, v=.enera c:Onc Or honlcO (cL cle oat) and 'gave Hired
the contractors listed beiow -,-0 o h� the `oll r e ^;
-,,v mg v�or kP s co%!D nSa:tOrl
(Name. of Contactor) (Ln_u�ucc Conn;:- Pc!icf Nunn r) ;�X, rn'ulon Date)
(Name of Contractor) (Tns m.ncc Numb--r) m Date
(Name of C.oatnctor I ___.---
(_om ti_Late)
- (Name of Contactor) - - (T-aTIratic- CoTrT-:--}/Policy Nu.mh�lr) - (E;:pi-:tic Date)
(r.ttidl_.d-!iticril i.:ct:-.._ -.- :n..._• .:-K:..,..... ,- -... �i;.+:<:.o.._,..-�
( 1 <llTl i. OIC 1)1 Opr]t t0i itit 1 h v:, 110 Ot:' for IP
j Aim <? home ov"n—
NOTE:ptcaae t+c nt+arc tl:s:•.,�•i)c
not trx-cc Lh.a thmo uni+i ir:tc{;cl:he
c '•71oYc3 u_z cz the n r ((3L152 a 1(Sl;,a,:;iin:ia.l,v hnt•icoa-ncr`cr a t ccu ct
legal vwuc of an==ployor under tho We kC%'&C,,1-a=iiion _et
[undc--zt. d thL a cvpy of UL-A ctaic::=.;:—y bn f,,,;-j j to tt'r_[y_txirtz�ccL of In�u:riJ An�r..m�Cupp or for Vl
COvriy&c vaificlioc and that failure to:ter coti`tr_g^.,ut•.3c::c"icc 25A of?.iCt,152 can Icsd to the imposition c;
COOStstmg of a fur_of up to S 1-500.00 n:t&,cr tr:;iri ti:_of::p to cr..}- e:.I civil xncltiu in do is nt of.,S!c,`Vern..Chia_r.:1 it
firms of 5100.00 z day q!uwa m:.
Foe dc{:uutnt�u.o uil y
i?crinit NUITAX.r -- 1
�7c,IM LU IC" ..,tcca':C'J�l'°_fill ittr_c, -T; L
ap
SECTION 8 CONSTRUCTION SERVICES -
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: /`+( cs (—)t0gL0q O
License Number
K10 A)bito
Address Expiration Date
signatu Telephone
Not Applicable ❑
��eaES�re" Yinetfirrrpravemen` C"o�acta� �- � "�: ' ' �t�;`
Company Name Registration Num er
' lb —
d ress Expi atio Date
a —Telephone Jr5/K
SECTION 10-WORKERS'CONIPENSATION INSURANCE'AWDAvrr(r :GL c.12,'- 251C(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...... ❑
tea,
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
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9
SECTION 5-DESCRIPTION OF PROPOSED.WORK(check all:applicable)
New House F-1 Addition ❑_; Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (M Siding[C71 Other(a
Brief Description of Proposed
Work: 1 1?
J 41
Alteration of existing bedroom Yes No Adding new bedroom Y No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a f€(Vew t`o se rt -orva "dl �a ci x�t�>ic ous i c�b p>�et+ t o NOW":
^
^f bu;,Id;ng' One Family Two Family Other
a. vac v ...y ..
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
L 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-Td$E COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES"FOR BUILDIUGR.PERMIT
7tAas Owner of the subject
property
hereby authorize
to act my behalf,in all a ers relative to work au horized by thi building permit application.
Signature of Owner Date
as Owner/Authorized
Agent reby 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 Parne
3b
Signature er/A
of gent Date
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Section 4. ZONING All Informatioh Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Dcl-m ent
h
Lot Size '
Frontage
Setbacks Front >-
Side L:° R:i f 'L:= R:I !
Rear --
Building Height
Bldg.Square Footage (� % i
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
Fill:
(volume,&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 Dow KNOW 0 YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON-r KNOW 0 YES Q
IF YES: enter Book ! Page and/or Document#' I
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained Q , Date Issued:
t
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO Q
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 0 . NO
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IF YES,then a Northampton Storm Water Management Permit from the DPW is required_
ep�use
City of Northampton statics°ot Pe, , Y
Building Department ec bictwD-
212 Main Street Sewer7S ptic . ifiiy
Room 100 vtWAft0/Wet, l�rar at
Northampton;MA 01060 Tv+to sets of StnicftiraG Ptaris ' � ��
phone 413-587-1240 Fax 413-587-1272 PtoilStte Plans
ether Specify _
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1. SITE:Ii!IFORNFA'FION
ifirs sgctt�Qc �trTie coinpl "orlfiice
1.1 Prooerty Address:
-
EtcrrSt District - CB D�sirict
S1�3 PROPERTIFOWNERSHIP{AUTHORIZED IGEl7`
2.1 Owner of Record:
i
Name(P' Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
6n dat Cd
(Print Current Mailing Addr
Signature 4 Telephone
AP W6 TIMATEEflCO SERUCTTON O TS
-_ .._-
Item - Estimated Cost(Dollars)to be Official Use Only
completed by rmit applicant
1. Building i :(a}•guilding=Permit Fee
2. Electrical _(bk Estmated Total Cost of
-- _Construction:firo7n 6
3. Plumbing 'Butiding.Permit_Few
zs.cto
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number 9, 300 ZS•U�
SectioEi Eor Elt€ieia[,Use:On
_ Date;.
Building Permit NO-mber. issued:
Signature:
Building.CommLssionerflnspector of Buildings- Date
er
.F0'#BP-2007-0026
APPLICANT/CONTACT PERSON Cyrus Newman
ADDRESS/PHONE 697 Bridge Road NORTHAMPTON (413)586-1093
PROPERTY LOCATION 47 GILRAIN TERR
MAP 29 PARCEL 062 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
uildin Permit Filled out
ee Paid 0 0
Typeof Construction: Shingle over one layer of roofing
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 FOL WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO TION 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
xg— 11L'eJ –07 t 0
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.
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BP-2007-0026
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building.
Categor BUILDING PERMIT
Permit# BP-2007-0026
Project# JS-2007-0041
Est. Cost: $500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Cyrus Newman
Lot Size(ssq. ft.): 16204.32 Owner: WILLARD JAMES J&PATRICIA M
Zoning: URA Applicant: Cyrus Newman
AT. 47 GILRAIN TERR
,plicant Address: Phone: Insurance:
697 Bridge Road (41-1) 586-1093
NORTHAMPTONMA01060 ISSUED ON:711012006 0:00:00
TO PERFORM THE FOLLOWING WORK.-Shingle over one layer of roofing
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 7/10/2006 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner- Anthony Patillo