32A-153 (18) O��x�PTO
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DEPARTMENT OF BUILDING INSPECTIONS
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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 his/her construction supc:-,'i 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 project until such time as the proper permits and inspections are
made
I, 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
I C, dill of Na rfllalliptnit
6 !}.Y�l1S AC111ISCiIS
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DEPARTMENT 01' BUILDDJ G INSPECTIONS
212 Main Street ' Municipal Building
1rorthamptoil, Mass. 01060
WORKER'S CONITENSATION MSUIZANCE AFFMAVTT
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---------- ��ICvP.;^_C1C'riII]IiiCC)
v:rith a principal place of businesslr :;donee
1_$3 P � ���1 -R n- (.aRe ►,' =p� 2 -r-P _97J c�
do herCb}' cci-Li Y• und;--n- the 1)<:ii]S t?ii7 pC i]ait1CS Oi 7f;fJllr�' t112:
12ril an CIIlp!O}'ei providing the r011o'+.''i[]C '•:OI'r;CI1S OIIIpCI]S�11UOII GOVCr2 C for IIly
eltlployees wo6drig on t'lis job:
a='L anG Compam') o c:Number) ----- (`rte,irz r)Date)
l j I and a sole proprietor, vrenPral c-Sn1a-ac`or one i and have 'tared
the contractors Listed beioti-� vv ho 114 the `oll ,. ;jorkerS comotn�t on
(Name of Co.nL-=or) Urns, mncc C^vI^^ r'i�G11Cr T4u n _r) (Ti'_?.` :+..iOG Date)
(Name of Contras or) -- (llzsJrrc Coy pa::`vPo!icr N + tr r) (I iir Datc)
(Name of Contractor) (lnsumnce COQ;'? 'iI O1;�, Tv'iLfi?I'r3i) \i,ir Co late)
- (Name of Contactor) --- (Itls rand Cemr ,y Polity Numbs*1 (L;:ri ::ic'r Date)-
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!!! 1 illll cl SOIC prUl?C1CCC)i cliitl ill?V:: iiC� Oi?'' .�3r��siit, t01- i11C..
I �i11 ? }l0il?C Olr;?l Dent "1?11I1 11l iL ii.`r lf.
No•IT::picric to aware t1:a:-w!i Ile txtr�o«Zr_.1 t .�c:_.�Ic+,r. r n > �•-%:�nc4 a:: n r m cr::,;av
not rzxre than thrco uai+s in or
employe--Z ucsricr 4x tvc:};c :ar •�>a_ix''rt((ii.I52 z I(5)),a,:l;c;.'ic:;lry a horrcon>cr for a li c a p.fm:d
legal rwuz of an a=vloyer and r tb-Wukc,".
I undczra.nd dhit a cony of this ciatc:s:rn.v b,,taw+udaJ to 11r of Inclirstrial Ciucw of for 11x
covcr-t&c vQifictioa and that U- rc to t:rc co rt; ul- ::c-.iCC 25A of M01,152 can Im�i to flx i�n�siiia +3t cif R�'I=c
comistLng of a flux of up to S 1.5Moo a:t1'rr i^;irr•.. r,zti:_011.1p to cn:}-ar r.-.i civil perultic:in 1"4 Ic 7n cf n S!r.,
Lre of 5100.00 a dsy agairnl rn.. .
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SECTION 8=CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : l re "J,
License Number
Address Expiration Date
Signature Telephone
Reg s ere rn ma oueme nContractor Not Applicable ❑
1�2,�R� L d•,1 ST-E'i u-GT—l�fs� f O 0 2 l `j'
Company Narii6 Registration Number
Address Expiration Date
�LM /v14 01 U �—Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G 1-c-152,152, § 25C(6))
Workers Compensation Insurance affidavi must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance 9,rthe building permit.
Signed Affidavit Attached Yes....... No...... ❑
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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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SEGTIOTI �D S R PST ON OF PROPOSED�WORK cheek all a' I+cable x s
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [410] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: cot-MIA, M,. IK-reweK I L Zt'�d,�d-S ( '6CVWI1,
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached RolIVI Sheet C1
am ftN leaddition.nt exrst�n housin �com "1e::e efot.Lowtn
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. L �u" Dimensions
e. Number of stories? 21
f. Method of heating? 16-5 WA, Q— Fireplaces or Woodstoves AT-0 Number of each
g. Energy Conservation Compliance. ��``^^ Mascheck Energy Compliance form attached?
h. Type of construction c zbtD
i. Is construction within 100 ft. of wetlands? Yes 1� No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or cellar floor below finished grade MI A—
k.. Will building conform to the Building and Zoning regulations? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTdN7 WN R�AUHORIZATION ; TO BE COMPLETED WHEN
OWP(EiSAG�EN ONTR�ACTOR- LIES FOR B,V LDiNG,PERiVIfT
as Owner of the subject property
hereby authorize to act on
my behalf in all matters relative to work authorized by this wilding permit application.
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Signat a of OwnerV Date
as Own rl.Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to
knowledge and belief.
Signed under the pains and penalties of perjury.
LPriint Name
ture of Ow A nt, Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning 1
This column to be filled in by
Building Department
Lot Size
Fronta e
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 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:
k
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
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phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR AEMOLISH A 9ftE q O FATLY DWELLING
SECTION 1-SITE INFORMATION
- M �fcls�sectioctatre completes by office
1.1 ProuertyAddre
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SECTION 2-PROPERTY`OWNERSHIP{"AUTHORIZEDAGENT"
.1 Owner of Record:
VIR6,1 n/t� �. S � �N L PO Kok ILf GQSH6W lV f 051Q
Na 1ne(Print)Current Mailing Address:
Na
` Telephone �Q -
Signatu a Z�
2.2 Authorized Accent:
:pItk 1,e t'�� 4;-2- G449-�) f��
Name(Print) Current Mailing Address:
` 13
Signa re Telephone
SECTIO . ,- ESfIMATED:CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only,
completed by ermit applicant
1. Building ��� �SZj (a)'Buitdirig'PerT nilt.Fee,
2. Electrical 6 D O (b)Estimated Total Cost of
Construction from" 6
3. Plumbing 0 Building.,Permit Fee
4. Mechanical (HVAC) � jj i�II b
5. Fire Protection '-
6. Total = (1 + 2+ 3 +4 + 5) � 0Z� 1-6ech Number
This Section-For Official Use Onll
Building Permit Number: 0 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-0894
APPLICANT/CONTACT PERSON George Peppard
ADDRESS/PHONE 483 Park Hill Rd NORTHAMPTON (413)587-9750
PROPERTY LOCATION 32 STRONG AVE
MAP 32A PARCEL 153 001 ZONE CB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid
Typeof Construction: INTERIOR BUILDOUT FOR RESIDENTIAL CONDO
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included•
Owner/Statement or License 051040
3 sets of Plans/Plot Plan
THE F9CLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9KMATION 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 ssion
Signature of Building Of icial 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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32 STRONG AVE
BP-2004-0894
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32A- 153 CITY OF NORTHAMPTON
Lot: -00 CONTRACTING w`ITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate BUILDING PERMIT
Perrot,, BP-2004-0894
Project# JS-2004-1331
Est.Cost: $125000.00
Fee: $525.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin George Peppard 051040
Lot Size(sq. ft.L605!M4 Owner: SCHENDLER VIRGINIA
Zoning: CB Apl lican George Peeppard
AT: 32 STRONG AVE
Applicant Address: Phone: Insurance:
483 Park Hill Rd (413) 587-9750
NORTHAMPTONMA01060 ISSUED ON:3122104 0:00:00
TO PERFORM THE FOLLOWING WORK.INTERIOR BUILDOUT FOR RESIDENTIAL CONDO
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;. 1� Rough: 7/l/0 House# Foundation:
Driveway Final:
Final: Final: �� b b
Rough Frame: O k 7_ol,
Gas: Fire Department Fireplace/Chimney:
Rou1;►,:� ,.�
Z. � ir���;,"O'1` Insulations rl
Final://" -0
Smoke: (/ '�/' Final: OK / 1 -30
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THIS PERMIT MAY BE REVOKED BY THE CI OF NORTHAMPTON UPON:;g;
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeTvpe: Receipt No: Date Paid: Check No: Amount:
Building 3/22/04 0:00:00 2050 $525.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo