35-029 (13) L All
NOV — G cCQ4
DF T OF VOI E"�!N�'ECiIJ4VS
p "N'MA 01060
1
0
7 C
Q � �
'Sf�
O¢THM1p��
- Z
$ � �1lrlassacS�usetts
r
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building
Nortluwpton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction sup<.: zisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two farm
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 0gulations. 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, ,z, ��,�,��i�/,o� 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.
Daze 1
Address of work
location t,�) i VC.
s
9 f ;.3aitcflnscIIs'
DEPARTNIE14T OF DUILDI7tG INSPECTIONs -
212 Main Strcet ' Municipal Building
Northampton, Mass. 010GO
cO.RICERIS COilQENSA`IIGN MSURAP CE AFFM,,
(li ccus.^cJperzni ttcc) ..
%VI h a prti-lcipal place of businessl/residence at: ------
(phone-')
(s�tici tj/sZalcy�p}
do hereby certify, under die.pa-ins and penalties of penury:, :hat
( ) I am an employer providing die followine %vorlcers cofnocns�Don coverage for im
emplovccs Nvor>Dng on dies job:
(Incur-.ac Corer ) (Pclic:Nu_-bcr) -- (� :pir�tior.Date)
( I am a sole proprietor, general contractor homeowner c-; ie or!e) and have hired
I- coasactors Gsted below cgbo have the 100 es coo 'on policies:
(i+RIll: Oi COR! C -o (IR uranc-- Coinpany/PoUCi
- (Name of Contractor) (Insurzncc Comoan}rPa!ic,, \uncrr) (Ex.LMiion Date)
(Name of Contracia;) G sur-a-oc; ComP�an)•/PGUCy N;>sber) (ExpLim600 Datc)
(Name of Contractor) (InSuraIlc—C Comca-ay/Pobcy Numbr) (Etpiralion Darr).
(aa��l:dii�oc31 bca.il acoc �-cn c�c!utL infonn._ioo .
{ ) I am 'a sole proprietor and have no one wori;3ng for me.
( ) I atn..a home owner performing all the 1vork myself.
NOTE:plea be ew-uc r1,••wt Je hemcowvcn wt,c=ploy P--om to do cr nr,au-ork oa a d..c1LZ of
W m«t th_a t`3oe J in u'32ch the bomoo+wc reside or oo the p ounc+ zqpurtc�tberu z c ooc L�r.11y occr'd�ci1 w tic
eiiployc-s uncle the--- r -�---- 'aa Act(GUl S2-a 1(3)),applies ioo by a bOM.G.7Da fW a 6C=----o<Pcrmit rty--r&=tL-
Icg3!--of..a—Ployac uodcr dtu workOe,coo,,,, atioa Act_
I uadaR,ad des-00;7 of thi.mr.®cm m.y ba foa>.crded to tba D pnrcmcct orlas,id Amda%Y CT, of lr=W�fay th-
oovcrase vecif c=lioo and th_z L-iltac ro w=art Mvcrase I=des seeiioa 23 A of h(OL 132 rya lad to the imposirioa of aimiaal pcailtio
coact';rag of.fiat of UP to S I}00.00 andloc 6M?rucaax=t of up to ooc y=r ad avil pca.Itia in th<focm of.Stop WoA Ord-- rend.
fun o(S 100.00 a dey a�tialf t�
For�+�u.c drily
-• � �t �n` -- 5� pcTmil Numbcr
Lot" s
t arrr of Li�scrJPcrmiuci Date
SECTION 8-CONSTRUCTION SERVICES '
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
S Re istereiFllisme m ar emeni.Edhtractor� : r � "'��"`, ' _ Not Applicable ❑
Company Name Registration um er
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G:L.ir-452,;.§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...... ❑
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
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [] Addition E] ; Replacement Windows Alteration(s) El Roofing
Or Doors E3
Accessory Bldg. ® Demolition 0 New Signs [0] Decks [M Siding [[3] Other[vr�
Brief Description of Proposed
Work: 5?"ZS.l7-Ac-- G .Sh'c r1 eoLe
Alteration of existing bedroom Yes �No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
saw €`Ne` _krouse n drtio 'orce strn ousir g� iftbl,06--th th 16(16WId"
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 OR CONTRACTOR APPLIES' FOR'BUILDING PERMIT-
I, ram e- Y 1 as Owner of the subject
prop
hereby authorize
to act on my behalf,in all a relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Agent eby 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 Name
Signature of Owner/Agent Date
Section 4. ZONING All Informatj6h 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:1 ' R: a__- L: R:��11
Rear =1--
Building Height
Bldg.Square Footage F-71 E % j
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 0 DONT KNOW 0 YES 0
a
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 0 DON'T KNOW Q YES 0
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 Q 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:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O r NO
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
_ f Nortompton
r-
Cding Department
___�-------� 12 Main Street ewe seal
oom 100
5 2004 N`` pton; MA 01060 . ets UXUCEUraly. r
NOV 41 -587 1240 Fax 413-587-1272
n�fF x W
I AI}PtCFiTli9�l,#� ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Property Address: TFus sectto to be completed°` ice
-
/� L,n¢ �Ck_ �'✓1 v C7 f Zone OuertayfDistnct
Elm`St:'D�stnct CB D4sfr�ct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: _
��—a t2sue' tgA/✓a/ L.-/A 1 ly �. � ft�i%lCLII �Xl✓c l L��[C�C� ��11� L�/G �"
Name(Print) Current Mailing Ad ress:
Telephone
s
Signs ure
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED'CONSTRUCTION COSTS
Item . Estimated Cost(Dollars)to be Official Use Only
comp leted b ermit apolicant
1. Building % (a)Building Permit Fee
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 Onl
':Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0562
APPLICANT/CONTACT PERSON WALSH BARBARA A
ADDRESS/PHONE 54 DEERFIELD DR FLORENCE
PROPERTY LOCATION 54 DEERFIELD DR
MAP 36 PARCEL 029 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid ;775140' ORCO
Typeof Construction: ERECT 8 X 10 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INYO
JAMATION 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
OF
Signature of Building Official Date
g g
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.
54 DEERFIELD DR BP-2005-0562
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-029 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinci DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0562
Project# ]S-2005-0741
Est. Cost: $281.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg_ft.): 31188.96 Owner: WALSH BARBARA A
Zoning.URA Applicant. WALSH BARBARA A
AT. 54 DEERFIELD DR
Applicant Address: Phone: Insurance:
54 DEERFIELD DR
FLORENCEMA01062 ISSUED ON.-11/17104 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 8 X 10 SHED
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:
FeeTvpe• Receipt No: Date Paid: Check No: Amount:
Building 11/17/04 0:00:00 2766 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo