29-110 (3) o4�"M'Pro
lity of Wartt amptan
�1A38ACtt liSttf6 -
DEPARTMENT OF BUILDIN G INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060 5
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sups ,, :.or. 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 sour), 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
I, � -�' �Y U ^�`-� 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
� �s�cssxc}Ittsrtte _
-ill Of -artilaillpfoll
m DEPARTMENIT OI' BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WOPUCER'S COMPENSATION INSURANCE AFTD)ANq.T
i
,:pith a principal place of business�r s denc
C{O heteUy CCI�IIY. lln:'ci tI1C pa'.i1S ?.nc pCn<it10;; Oi pf;l,lll-', than
( ) I am an employer providing the iollo.v;Ia, KCT-S COlnnensation COVCr.�;c fo- my
cttlployees wor4drlg on t?iis job:
jnssrancz Corap:m') c c,Nttrntxr) --- (`r�> r ion Date)
l ) I am a sole proprietor, yzen-r-a l Cie Oct) and hired
the contractors Iis e beio, ,v ho l:� the `011 er ron r ! 'es'
-ortt scot. pen_ •,o�c. .
(Z`;=c of COrlt7<mr) �nSL`nC CvI ^;:: t: ) ?:;' :. Datc)
c1ic; Nuln�r .ice
(Name of Contrac',or) -- (Ii1S1r=P.C° Con rr�IPe!ie Number; (Expiralio Dale)
(I"lame of Con'tI'nclOr) (InEu' acc Con, ?il'ii?ol;Ci NuII hw r) Dale)
(Name of Cont-t-actor) (Ias1 rare C1 olier Nu.mbu) (F:;:r; -:tior Date)
(^(LiGl:.d-±iti crif z•._ct:..._'_... ::�:.r_}'�:::.:'r°:C:c.'�__._..:r;,'.-eli..a._._..-...-)
I ILn cl sOiC plUprlC�C?i ?I:1 ili?VC
110 OI1^ "t�ilil; 101 ille.
} I �itl ? 1:0?Z?e CW?lC" 'liCi:O"I?11I r' 111
NOTE:plczsc be nlrarc tl.a:•.vL;]c h<nco :r s"tro c;pl. • a::: c im cr:.pair., .._-..
not UXxc th:a throe uni!s in«i c't Lhe or a;` _.-,�z urtcc r1 LhcRC e c n t�encrally crr_`' :o h
e '.pioycz un et the wcri;�s ca z- :earn rtt (GL,I 52_r 1(S)!,at:, ._::ia;by m h rixtt>cr:`or e Lccu cc prim: n c Lc
]cgal ctatuc of an e=Igloyx under tho wo icla coi,w_-ikon xL
[ua&-_nand th+t a copy of t}v cta stay bo fcnucJ J to tf»IY.SiurIInc:it of I,:>driJ Ac6dm=e Liiao of for llx
covcr<gc vcrtjtrlioo and that f it rc to r c rn�-rn�ut sc�.iM 2 5 A of MGr.152 can lc--d to tlx imposition ,'"r
c`Omisling of a rtnc of up to S 1.500.00 n:tom'Y i :prxr,Z :'1 of::p to cr..}- e:,I Civil prstzftia in 1•c f(- n Of-I S!r,,`;'c i.Ch _!1 e
f rm of S 100.0 s day i rr_in:.1 m:. .
For ciq:�v: t1J t,k"y
Ycrmit Nuuttr..r _ __
i
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Ji�naturc of i.ic�n xJl?crnuar:c ;r f
r
SEC. '0 8 .:RCONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
�Reg' sf ebme1"mpro�ue�menf`C-/n ra * N Not Applicable ❑
Company Name Registration Number
Address �— Expiration Date
Telephone
SECTION 10 'WORKERS' COMPENSATION INSURANCEFAFFIDAVIT(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....... ❑ No...... ❑
HIM
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 5LII
M
„SECTIONS=�I�S R:IP7 OTI1O.F'm 0PbSED WORK cheGk�ail a" I�cable
New House ❑ Addition ❑ Replacement Windows Aerations) ❑ Roofing ❑
Or Doors ❑
Bldg. ❑ Demolition❑ New Signs [ ] Decks [ J Siding[ ] Other[ )
Brief Description of Proposed Work: S 1 r-t r,-,- vA%,,L q e,v S C w— r�ri4 G
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ • Sheet❑
6a. Ifl ew uo sera d°° �dii:i-tton: o exi-sung h using omp`ke a he follow ng
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
SEC��bN,�a �VYN;EWAUTHORIZATION 'TO'.BE!COMPLETED WHEN
OWNEkSACEN FOR AC LIES FAR �UIL`�ING HERMIT;
as Owner of the subject property
hereby authorize ✓^; 7/!-c � �'��,, � , � to act. on
my behalf, in all matters relative to work authorized by this uilding permit application.
Signatur 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 pains and penalti of perjury.
r.,.5 r I Gi r �
Print Name
Signature of ner/Agent Dat
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 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT 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 .
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
,
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A t�`NE'6R Two F�kI Y DWELLING
AFR 2 0 X004
SECTION 1-SITE INFORMATION
st T is see°CQmpletec1iby offi
1.1 Prooein Address:
RY 0 K.s
Zone Overlay D15t1ICt
.-ice,.
lam St.DIS1 rICE a CB IS1l17Ct „: ._. ry
SECTION.2-PitOPERTY OWNERSHIPJ-AUTHORIZED'AGENT
2.1 Owner of Record:
eCo1-G->r
Name(Print) Current Mailing Address:
U Telephone
Signs re
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION-COSTS
Item Estimated Cost(Dollars)to be Wcial'Use'Only
completed by ermit applicant
1. Building >(a)`Bullding Permit Fee
2. Electrical (b) Estim Total Cost of
Constructiated_on from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection -
6. Total = (1 + 2+ 3+4 + 5) � 7, Check Number 7w o�`J
This Section For.Official Use,Only
Building Permit Number: ��d`� '� 30 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
it ... _. 1►
584 RYAN RD BP-2004-1030
GIs#, COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 110 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-1030
Project# 35-2004-1551
Est.Cost: $9317.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 22520.52 Owner: O'BRIEN GEORGE&RUTH
Zoning:URA Applicant: O'BRIEN GEORGE & RUTH
AT. 584 RYAN RD
Applicant Address4 Phone: Insurance:
584 RYAN RD O 584-8255O
FLORENCEMA01062 ISSUED ON:4128104 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE HOUSE & GARAGE ROOF
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 Sienature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 4/28/04 0:00:00 1876 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo