35-220 ¢'St1Aa1P�.
Z
� (} �tr assachuseffs -
r
of Worthalliptan
� DEPARTMENT OF BUILDI TG INSPECTIONS
INSPECTOR
'212 Main Street • Municipal Building
Nortlnunpton,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 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 fami1y__ -
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 fegulations. 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
r
1
iy •
i
O
(rii-�) Pf {crrfl1aliiptoll _
-
.6;•5aACilnsClla'
c✓ DEPART1`4EIJT OP BUlLDr7\C INSPECTIONS
j 212 Main Strcet Municipal Btidding
Northampton, Mass. 01060
i
«`ORt4It'S COIII';✓NS TLO.N G`1SURA. CF, AFFD),1.Vj-j-
i
i
(li C=S=/PCrrrli ttcc)
nth a principal place of business/residence at: --
i
U )
(srr�-t/d rrfsiatcla p)
do hereby cerifj-, under dic.patns and pe11216es of Pcgw-y, -!h al
am an employer providing the following.vorkcr's cotnocnsaLIo, covcmsc or Iny
elnplovecs wor ang on tills job:
I
(Ins1u-n Comm) (PCUC-, (r;pirtior.DzL)
( ) I am a sole proprietor, ngeaeral contractor or homeowner(ci cie one) aad have hired
the couiractors tasted below rybo have tht 11000 wing workees comoen_sadon pokies_
(I+nmc Oi Contnczor) (IRnlranc Cornpan)-Pi o lc{ } UM*_r<:) �YLJIi-J Q ��ILC)
(Nzmc or Cona-zC r) (Insurance Comoam aPouc: `umccr) (i.»ir,oon Dar-)
(Name o(ConuacLo;) (Insurance CompanyfPoUq- Number) (Expirdon Date)
I
(Nzme of Contractor) (Icuuran ComramylPolicy Number) (Expiration DatL).
(atxs. ad:i;:•oc31 t;cct.iracoa�.-y to incuc�iaroCm�zoa per%i ni.as to.11
II
I am a sole proprietor and have no ooe wori;3ng for me.
( } I am.a home owner perforTning all Lhe work myself.
NOTE:pl c be ewlrc tt,. ,{ }e hcmrAvvcr�wto c=PIax Pezoaz to ;,-..—, shoo C rgaII work out d..�tt:-a of
oo(mete th.n tam t=ry is wbkh the bomoowocr nc d,�oC oa the p,,z,6 zppurteny thcco c:T oo( a.-c_:d=md to be
eixploye�unc'.e the-=kd-cm:;lioa Act S2_=G L'1 1 5
t ( )�=ppiiaboo by a bomaoa=fcr a lies_a lxz:ait rs_y et-id—tie
les-,crams or ea c Playw uod, rho Wockoe.Coa*P ==lion,let
I uodasta,od the a coyy of tai,cal—cut t y be fac-.. i d to tba pepnsemmr orinda+xs;rJ As &=Ly C>JL—of Iour.00e fa tb.
oovcrasc rcrwCxxioa and Ot_t U-Lrz to so==`M%-cm o coda-1,0 c oa 23A of MOL 112 c.ieJ to the impcuuioa of Qimiazl pcu-W-
ooazi.a g or a tine orup to s 1�oo.00 an&cc pruoameri orup to Doc yet cad civil pca.hua is d e fccm of a Stop W-A Ord-and
rim of S 100-Qo a day tFpiaA tax
F«dqp^ "t u,e Dory -
Pcrmtl Numtxr
✓ sic - �{ap Lot..
S i i of Lio�sccJPc tau e
SECTION 8-CONSTRUCTION SERVICES {
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
re Telephone
S:ReaistereConieTiti'ti�o�rerrteiiatrac' k „d � Not Applicable ❑
Company Name _ Registration um er -
Address. Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(W:'G.L.c.i52-;§25G(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...... ❑
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
r
t•.
SECTION 5-DESCRIPTION OF'PROPOSED WORK(check'all applicable)
New House ❑ Addition ❑.; Replacement Windows Alteration(s) ❑ Roofing E
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[o] Other[E:3]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes f No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes L- No
Plans Attached Roll -Sheet
6a (�[�ernr��IO�se�n �ac'c�t�otamexs" E��3ao�ts�nc.�.,��ar�p�et�.t��a f��>I�eg:
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 COMPLETED WHEN
OWNERS AGENT.ORCONTRAE'FORAPPLIES FORBUILDtNG PERIVIII
as Owner of the subject
property
hereby authorize Q
to act on my behalf,in all ma ers relativ o work authorized by thisibuilding permit application. �.
Signature of Owner Date
ri?
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. '
r �ClsJf /�/I."r !s ✓Z
Print Na
Date
Signatu4of Owner/Agent �%
'
'—
Section 4. ZONING All Informat-i6h Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Building Height
Bldg. Square Footage % F-"'
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(vclume&Location)
A. Has a Special Perm it/Vahanua/Findi er been issued for/on the site?
NO 0 DON'T KNOW YES 0 �
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO �~��
� uum / w""= .^^
IF YES: enter Book Page;, and/or Document
�� ��
B. Does the site contain a brook, body ofvvatarorwetlands? NO ��7 DON7K0OVV �~� YES v��
IF YES, has permit been orneed to bm obtained from the Conservation Commission?
~
Needs tobeobtainmd »~~� Obta�mad �~� 0etmUssued'
v�� x�� ' �
��
C. Do any signs exist on the pruper�? 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 0 NO
.
IF YES, describe size, type and |ocat|on:
E Will the construction activity disturb grading nr filling)over 1 acre orisd part ufo common plan
that will disturb over 1acre? YEGK ) NO �7
-�^ � ~~�
|F YES,then a Northampton Storm Water Management Permit from the DPW isrequired.
City of Nortf ampton P
Building Department w
212 Main Street
Room 100 e r�
Northampton; MA 01060 earrc
pholne 413=587-1240 Fax 413-587-1272 ° a �
r, ��
theme s �� N,
APPLICATION TO COONSTRU T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE1NFORMAT,ION'
1.1 Property Address:
Thrs sectror�to be camPletedibxoffce
•.��� �./� /J�/ j'!- / /A"c",l: ��l ti��� Ma� Lot � � Unto
Zone `' =Overlay Drstrrct.
�=
Etu%Sf Distc►ct GB prstriFt=••.,.
,.__. . _.. .� , 5..
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
E ! x51-A/►� E/� �'�'.%,F lizi - ,�' h';=r" /ayfir Al
Name(Print) Current Mailing Address:
Signatures Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS,
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
�Lv �-
2. Electrical (b)Estimated Total Cost of
Construction:from 6
3. Plumbing Building Permit.Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Sectiorf:Fbr Official Use Only
Building Permit Number. Date
Issued:
Signature: r
l
Building Commissioner/Inspectorof Buildings Date
File#BP-2005-1079
APPLICANT/CONTACT PERSON SERGE BELANGER
ADDRESS/PHONE 173 MAIN ST-APT C EASTHAMPTON (413)527-2414
PROPERTY LOCATION 30 LADYSLIPPER LANE
MAP 35 PARCEL 220 001 ZONE SR
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: REROOF&INSTALL 2 SKYLIGHTS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 056293
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF91MATION 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
>C --
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 Comnussion,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.
30 LADYSLIPPER LANE BP-2005-1079
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35-220 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2005-1079
Project# IS-2005-1470
Est. Cost: $7000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SERGE BELANGER 056293
Lot Size(sq.ft.): 40902.84 Owner: MEEHAN KERRY F&DONNA L
zoning: SR Applicant: SERGE BELANGER
AT: 30 LADYSLIPPER LANE
Applicant Address: Phone: Insurance:
173 MAIN ST - APT C (413) 527-2414
EASTHAMPTONMA01027 ISSUED ON.5 116105 0:00:00
TO PERFORM THE FOLLOWING WORK:REROOF & INSTALL 2 SKYLIGHTS
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 5/16/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo