35-219 rx
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` DEPARTMENT OF BUILDITjG INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building '>e
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 his/her construction sups;:"isor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,a one or fivoanu --
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 buii mg-department-for the City oTNorthampton 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 eegulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings(before backfiIl).
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 occupancv
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
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LT{� 1 {LTZ"f 1 13111 1
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�ila�a�crr�trtrua• �
DEPAR ME17 OP BUIL.DD\10 lNSPPCrrOr.S
j 212 Main Street Municip.ai Building
1 Northampton, Mass. OIOGO
WORKER'S COVIII'ENSA77O.N LASURA-NCE s•IFT)/it'1T
p;�nsxJperm;rtcc>
%lath a principal place of businessfresidence 21: - --- -
/ �"
t'j/staitfa P)
do hereby ccr-6f=, under Lhc.paim ;md penalties of perjury, ha►
I -
( ) I ion an employer providing the following i,vorkcrJ5 cotnocnsa io, covervge 'or In),
emplovees V;'orlong on uus job:
(L=u1---n= Con,- n,r) (Pori=-,- Nu--zo`r) -- (:-pir`tion Dsr.)
i .
( ) I am a sole proprietor, general coca-acror or homeowner (c cie one) and have hired
the cona-actors lined beJo%v wbo have the foOo-,vino worker's comoen_ta'on policies:
i
I
(N=c- Of Conr^Oior) Grisurznc; CoIno1A)•/-oUci NIUML: ) CE:�:a1FJtjoi nalc)
(NaMc of Conc-aaor) (irssranc° ComDam-iPoum, `tsncrr) FEiDiraon Date)
(Name of Conrraao;) (Insu.ran= Compareyipotic)• N:ISb r) (�Lepirrien Dalc)
(Namc of Cont actor) azalran= Comr ZYIPolicy Number) ( xptnuoa Daac).
(aII�r.11:d:ii�oczl cC,if accC.u_-ti to ir> lu&iaformi-ion Pcta.'�to.,1.1 ..
(l�I am a Sole-proprietor and have no one working for me.
( ) I am..a home owner performing all the work myself:
NOTE:Plcsc b cwxrc t%.. 4Jc bcmrn�x..bo==play P=-.a=to clD rcpa -ork oa a d,,--LL--Z of
ont Moro lb-Z ` r._L-anj is%i' the bomoowDcr roach or oa the Vovz,,:s zp7,rL,=�tbe• c ox C=�rny xc-:d--ni to tic
t ==ploy=s the kui�C==P=;-1ioa Act(Gull 52=1(5)).=,)pli---L6oa try a bomc*oa=for c tip_or p=air ra--y the
1e5%1 n"^.of as ezployer under tho Wortkse,Cocxp.om *o
f auadc^sx�ad tiz+¢x copy or thi. m be for-..u.-d to the
Y Dcgsrcmcoa of Induxr;cl nccideatz'OT—of l—+r•ooe for tiJy
! cov='Zc veiGcaioa nod tlit L-ltac to Lc= 'covn-aCc uadc socZioa 25A of MOL 152 cna led to the i=p=itioa of eimiMI PctuL•i=
mmij ag oCa fiat of tip to S 13oo.00 arm« oCuP to oar y-_r and cvi7 pm.ltic is tSc form oCa Stop Wort O do aid a
j r=oCSIDO-DO any c�
/// For _.,t u.c only .
�/ �r�� PtTIIIII )�tlIIIbCS - — —
( ( ),dap.—_ Lot R
I 9;Qattur of LiQS--cc/PcnTuu= e 1
SECTION 8-CONSTRUCTION SERVICES {
8.1 Licensed Construction S ervisor: Not Applicable 0
Name of License Holder: 6 G-4 b
License Number
Ad ess Expiral on e
l� 6
a re / Telephone
:Mtftere`Ud—r e�moi`o emei zonb=tor z .,° Not Applicable ❑
Company Name Registration Num er - _-
Ar
Address -� r Ex rati n Da e
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVtt(M.GL.c.152,§15C(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
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [Ed Siding[0] Other[�]
Brief D, cription of Pro osed g� I
A ei�lJ� /'G�i'C`� J'��rC L"X/s c'V'Clue c /nA& ' /`CCL S •5��' �
Alteration of existing bedroom Yes No Adding new bedroom Yes
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a]�=�18Y1i X101754'aRC�=�liC 3C litLOCk�Q:�Xi S�ICtCIOltS111Q':cor�ptet�*the-� iaW><nq:
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.-TQ,BE,COMPLETED WHEN
OWNERS AGENTORCONTRACTOR APPLIES`FOR BUILDING"PERMIT
I, ctw
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` as Owner of the subject
property r
hereby authorize
act on behalf,i afters relative to or a rized by this building permit application
S- D
ignature of Owner Date
l0 as Owner/Authorized
Agen hereby declare that the stat me nd information on the foregoing application are true and accurate,to the best of my knowledge
and be ie.
Signed under the pains and penalties of perjury.
�o
Print Name
Signatur of O er/Agent Date
Section 4. ZONING All Informatibft 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
Side L:° R L: R.
Rear
Building Height
3
Bldg.Square Footage j;; %
Open Space Footage %
(Lot area minus bldg&paved �--—1
azkin
#of Parking Spaces
Fill:
(volume,&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO v DONT KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
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 Q Obtained Date Issued:
C. Do any signs exist on the property? YES 0 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 location:
E. Will the construction activity disturb(clearing,grading, tion,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES r NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
-t of Nort�ampton
(\ it i6g Department �'°
'Main Street
om 100
No ham ton; MA 01060
S587-1 40 Fax 413-587-1272
LICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address Thrs section to be completed by office
SIi��E%� Map �t Utart
.9 ' 4?reflays,"D ct
'Elm Districi :� GBDistrict
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED>AGENT
2.1 Owner of Record:
T(kO4A&e r h 1Aj,'
Na (Print) Current Mailing AddKess:
Telephone
ure
2.2 Authorized Agent:
Name(P' Current Mailing Address:
y/,? - 58'6 - y76 Z
ignature Telephone
SECTION 3-ESTIMATED°CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
competed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical vw (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection fit
6. Total=0 +2+3,-+4+5) Check Number
This Section For Official'Use Only
Building Permit Number te
r.
Issued:
Signature:
i
Building Commissioner/Inspector of Buildings Date
File#BP-2006-1344
APPLICANT/CONTACT PERSON C&T Construction r"'4
ADDRESS/PHONE 15 Fairway Drive FLORENCE (413)586-4965
PROPERTY LOCATION 26 LADYSLIPPER LANE
MAP 35 PARCEL 219 001 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: CONVERT 14 X 16 REAR DECK TO 3 SEASON PORCH&EXPAND FRONT PORCH
TO 10 X 13
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License 062884
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
L 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 mmission
f'
�J 4�5/S zcaw
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.
BP-2006-1344
ow
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Catep,ory: BUILDING PERMIT
Permit# BP-2006-1344
Project# JS-2006-1991
Est.Cost: $25000.00
Fee: $125.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: C & T Construction 062884
Lot Size(sq. ft.): 57499.20 Owner: CAPLAN JAMIE ANN
Zoning: SR Applicant: C & T Construction
AT. 26 LADYSLIPPER LANE
Applicant Address: Phone: Insurance:
15 Fairway Drive (413) 586-4965
FLORENCEMA01062 ISSUED ON.6/16/2006 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONVERT 14 X 16 REAR DECK TO 3 SEASON
PORCH & EXPAND FRONT PORCH TO 10 X 13
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 6/16/2006 0:00:00 $125.003567
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo