35-233 (2) O¢�t1AMA
, Gity of Wart4alliptan z
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DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building
Northunpton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as l is/her construction sups:-:iisor. 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
F `E 3 L7f �>�� fI}a111}�tnti _
4 flaoancilncclfa' _
4 d DEPNtTME117 OP BUIL.Dr),,c INSPECTIOI:S
212 Main Strcct IN-funicipal DuildinE
Northampton, Mass. 01O60
tip'OMCER'S COYQ'ENSATION MSURA'CF Al=A1'17'
(l;ccnsxJpertn�tftx)
th a principal plat, of business/residence at:
(phone')
(st/ci ty/stauh p)
do hereby certify, under the.pamns and penalties of pefJury,- i.hal
( I ern an employer providing the iollo.vine %voricer's comocnsa:Jo, cove Ige (or lnv
emplovccs wor>ong on uiis job:
---
(Insu r'an Conr ) (Polio:ivy-err) (�:-piruor, Dom)
( ) I am a sole proprietor, general contractor or homeowner (ci C:e one) and Have hired
the contractors listed below wbo have the follo%vins workers cocntasa6on policies:
ONZIM. Oi CO:`-'^C O-) (lRR r'7)C� Compare)-/-PoUc NIUMII -C:)
j
(N;mc of Cootraaor) (Lnsarance COMDanv/Polim N'Lum cr) (L-Dir.:tion Date)
(Name of Conn ratio,,) (Insurance- Comp2ny/Poucy N Lmb.i) (Expirriou Datc)
(N2me of Contractor) (Ins irancc Compary/PoUcy Numb:r) (Expiration Datc) .
(aII�ch=d�t:•ocal t'�ca.ifacocu�•to ctdv6c iaforcu.:�oa pccaiains to.11 cocz—=o.�) -
( ) I am a sole proprietor and have no one working for me.
( ) I am.a home owner perfor-rmc all the work myself.
NOTE:plc=be cwNt tfi••w1 }c bomcrn,n,.vbo ctaploy pc-soos to da -•--�,-,,•,-• cs.:.c�ao cr rc,as-atic on of
aot mote tt,-z t x=rz is%t s cb the bomoa%a rrzid=CC oa the p-V nc X97.L c�asrl the eo z-r o-x r_11y oecs d red to be
rxxployc-s uaP.c lbc u'ai:riz o�-,.--..,:m Aa(GLt S2-n t(S)��Plintioo by a 6ommavc for:lice.or permrt ca:y c.-id�oc tl:c
j Icgar cL-Olu of ea c=ployoc under dto Wortida Coo=pamition Act
I uaaa-naad the x Dopy oC thia�may be for-..nrd.>d to the pcportmcox of lodu.Y�;c1 nccadc�i'Offioa of lrsx+�ooe ror the
oovo�'c vciGetioa,L,d tit.-.t C.iltat to stair,bov�y�tmdrz xoction 23A of hiOL 1 S2 m lad to the�IIioa of Qimiail prnaltio
000si al g of a fiat or up to S1 500.00 utdlor n ,o oCup In one year e.nd o,il pco._pjo is tSc form or.Stop Work Ordcr.nd
fim o(5100.00,d_y ap i me
For dcp.rcm=�1 u.c oozy
// t'crtm�t l`t LiML-x
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: t,f�, �^- ��' a License 1 N 7,F
Addr Expiration Date
Signa ure Telephone
9_.Re`istereN mem"roireraent Contractor r ,$ s Not Applicable .❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(fi))
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 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
SECTION 5--DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑] Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors 71
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (M Siding[0] Other[CI]
Brief Description of Proposed , IA
Work: /
` `e S ��'� t h
e ltic't Po-tom
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa:-fev►rho�Seancl�o .d` rtiooXistincriousngmulee teottovu�na:
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`COMPL'ETED"WHEN
OWNERS AGENT OR,CONTRACTOR�APPLIES FOR:BUILDING PERMIT
f J IF as Owner of the subject
property
hereby authorize
t uV on my behalf, i matters relative to work authorized by this building permit ap icatio .
Signature of Owner Date
I �� �u►-+,htu/ 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 penalties of perjury.
Print N me
Sign ure of Owner/Agent Date
`
. '
^
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
T'his column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bIdg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Vahanue/F ever been issued for/on the site?
NO 0 DON70VOW 0 YES 0
IF YES, date issued:;,
IF YES: Was the permit recorded at the Registry of Deeds? '
NO 0 DON7KNOW
IF YES: enter Book Page and/or Document#'
~��
B. Does the site contain abrook, body of water orwetlands? NO t��x—� VV �_� v��DON7KN� YES �_�
IF YES, has permit been orneed to be obtained from the Conservation Commission?
Needs tobeobtained �~� 8btu�ned �~� Date
v_� �~/ ' '
C. Du any signs exist on the property? YES 0 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 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre orioit part cio common plan
that will disturb over 1acre? YES NO ��� �
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
`
City,of Northampton #afrlse�it � ��
Ildfing Department uratrrewa �
Main Street
a
;Room 100ata� r�� ��
NorE; m ton MA 01060e Stut �� k
iw
F.;
SE -'- h 41 Vii» -1240 Fax 413-587-1272 r6v. ,
1btl�er peclf w x �
rApfICATIQNi'TO CKLISU ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This sectron to be completed t*y office
1.1 Property Address: ,
N f �
�,�j B„�,r"r� �,{�► �M�p .fit unit
O G / Zone . OvedayDrstrict
CI]ISfrIGt "
SECTION 2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
pc,-V v
Nam (Print) Current Mailing Addres :
Telephone
Signature
2.2 Authorized Agent:
Aj 1I J
N e(Print) Current Mailing Address:
411 � — �y7 ' 0173
i nature Telephone
SECTION-3-'ESTIMATED CONSTRUCTION COSTS-
Item Estimated Cost(Dollars)to be Official Use Only
,-
completed by ermit applicant
1. Buildin (a)Building Permit Fee
Q oaf /�-0 60 0 a
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:
Building Commissioner/Inspector of Buildings Date
k.' 14 LA E, BP-2007-0248
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2007-0248
Project# JS-2007-000374
Est. Cost: $12000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GERALD ARCHAMBAULT 129913
Lot Size(sq. ft.): 123710.40 Owner: TEECE KATHY L&DAVID F
Zoning: SR Applicant: GERALD ARCHAMBAULT
AT: 25 BAYBERRY LANE
Applicant Address: Phone: Insurance:
263 PROSPECT ST (413) 552-7410 () Workers
Compensation
PLAINFIELDMA01070 ISSUED ON.91512006 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 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 Signature:
FeeType• Date Paid: Amount:
Building 9/5/2006 0:00:00 $25.001280
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo