35-302 (7) EN
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PNER of 'Nart4alltptanENT OF BUILDING INSPECTIONS ain Street • Municipal Building INSPECTOR � Northmnpton, MA 01060
OM MPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction sup: :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
1, 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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EN-1 OF PUIIS�RIG INSY£'CI'IONS �/
212 1�1-ain Strect Municipal Building
Northampton, I1Tass. 01060
WOB"KER'S CONIPYNSATION INSURA.NCY AFFIDAVIT
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elnployccs "v01kiII on 11,
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(Name of Lonl_actor) ���� C or, , ri'oL N111 l r) Latei
(N3IIlc Of Co111ac'LaI TIl _�2L� (�0!➢ 'J1,Cv TiIIiR��_II 1 ..i.'.C..;_.. D,
full a a'Ic., t;ll)f)�1� ,�� �l 1 ' . _ .:C- ;ill'._ 1-01
❑p!atccc thr_a tt:rcc uCil't 1:��{:.r_t:1� - s•.��_ - -a �. - - ...
Itsal rtahu of cn�loyx under tip
I undcntsnd t!u!>copy o£lha ctvr:�z_r:xy Fa:�_r�sw�!o�7 tv tl,o G-try tnx-.d of Irx?s;n al p,ct-ilrrti,'OI::e of is_:nr cr a for l}rc
covcgge vaificzlion and fhLt fnlutr to 2SA of b,Cil,152 can Iced to tlx:iml,�s:ial
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SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Su rv�is`orr:�/� Not Applicable ❑,,�//
Name of License Holder ,J ?7�`�'^''40 ♦ i� :(dGP -- L✓ � 'mil(
License Number
Address Expiration Date
Signa e Telephone
9"R g�stered Homelmproueme`ntContractor �^ „, . s,`, ; Not Applicable ❑
company Name Registrati n Nu ber
Address c� Expiration Date
10,0040 27 Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(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...... ❑
1 „.£-_ Hzome Owner elrip.tl; .n
The current exemption for"homeowners”was extended to include Owner-occupied Dwellings of one(1) or two(2)farniiies
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 f(,-which this permit is issued.
Also be advised that wits, reference to Chapter 152(%Vorkers' Compensation) and Chapter 153 fIl,iability 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
7
' SECTION 3-=DESCRfPT�ION=OF:PROPOSED WORK(check all applicable) ,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [lam
Brief Description of Proposed Work:_ i9�
Alteration of existing bedroom Yes No Adding new bedroom Yes
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll o - Sheet o
sa, .IfNewhouse andor. atltl'ition' o° zistin' fiousin" °com lete$the:followin` :
a. Use of building : One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms 2/y
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? lT/ Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. >>�� Mascheck Energy Compliance form attached?
h. Type of construction _!� /52:
i. Is construction within 100 ft. of wetlands? Yes G No. Is construction within 100 yr. floodplain Yes-No
j. Depth of basement or cellar floor below finished grade
k. Will building confor to the Building and Zoning regulations? _ !/ Yes — No .
I. Septic Tank 17 City Sewer _ Private well City water Supply
SECTION 7.a"OWN ER°AUTHORIZATION - TO BE COMPLETED WHEN
OWNEFFS.AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
X I Pam e, M akr e' _ as Owner of the subject property
hereby authorize _
to ac; on
my behalf, in all matters relative to work authorized by this building permit ap"tion.Signature of Owner Dat
as Owner/Authorized Agent
hereby declare tV the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed nder the pain
,�nd penalties of perjury.
f64 N
Print Nam
Sig tune of Ow r/Agent Date —
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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does t ite contain a brook, body of water or wetlands? NO UON'T 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 y
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:
-- of Northampton a $.
1h,ding Department G
Main Street
Room 100 a R
"03 N8 a ton, MA 01060
p T� a-Set
phone 41 58-1 -1240 Fax 413-587-1272 Site
- � ' ° 'PiREL 'C�tS Other Spactfy
APPLICA710N TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be-completed by;office
1.1 Property Address: - a
r Map Lot 1Jmt
Zone Overla strtct{
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2_1 Owner of Record: '00vo - ee"�e,
Name(Print) Current Mailing Address:
Telephone —
Signature
2.2 Authorized Agent:
Name(Pi int Current Mailing Address:
Signat Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
ri Building 4� Cox= (a) Building Permit Fee
2. F1= . ri �l '1' cc — (b i _,timated Total Cost of
Ccnstruction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) CC)
' ._..
5. Fire Protection _
6. Total = (1 + 2 + 3 + 4 + 5) Check Number _
_ This Section For Official Use Only
Building Permit Number: iMl Date Issued:
+ Signature:
Building Corn missioner/inspector of Buildings Date
File#BP-2004-0221
APPLICANT/CONTACT PERSON CORBEIL ASSOCIATES
ADDRESS/PHONE 148 PARK ST (413)527-9286
PROPERTY LOCATION 80 WOODLAND DR
MAP 35 PARCEL 302 001 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: FINISH BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 059611
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 sion
Signature of Building Official Da e
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-2004-0221
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: BuiidinQ
Category: BUILDING PERMIT
Permit# BP-2004-0221
Project# IS-2004-0319
Est. Cost: $10800.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: CORBEIL ASSOCIATES 059611
Lot Size(sa. ft.): Owner: MAURER STEPHEN C&
Zoning' SR Applicant: CORBEIL ASSOCIATES
AT. 80 WOODLAND DR
Applicant Address: Phone: Insurance:
148 PARK ST (413) 527-9286
EASTHAMPTON MAO 1027-2162 ISSUED ON:8128103 0:00:00
TO PERFORM THE FOLLOWING WORK.-FINISH BASEMENT
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• Receipt No: Date Paid: Check No: Amount:
Building 8/28/03 0:00:00 1350 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo