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Sheet No. l of
�HAMA
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$ � �'ilassacltusetts
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR •212 Main Street • Municipal Building
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 .,is/her construction super-:`sor. The state defines"Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or ivo fame y
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 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 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
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ISZI_-�) of �\To rill2dllipioIi -
A � E ��csarrchnsrlta'
DEPARTMENT OP DUILDf\'G INSPECTION'S
212 Main Strcet ' Municipal Duiiding
Nlorthampton, Macs. 01060
_ (:)r C:,IZ'S COWIPENSA770N G'� SUP CT-
(li c;.vs:zJpc�mi ticc)
With a principal place of business/residence at -
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(S'Lr�-1/C7 tyf a i r/II p) .
{� do hereby certify, under the.pa-ns and penalties of pc`Jw .., that
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( ) I am an employer providing die folloxvine'«orker's comacnsa:io, cove_fie for !n)
emplovees worlang on tills job:
(Irsnr��Corer ) (Pclicc Nunzbcr) -- (E-xpir-a or,Dam)
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( ) I am a sole prouriefos, general contracor or homeoi�-Der (c cie one) and have hired
the coati actors listtd below who leave the `ollo%viap- workes cOL;)ensa6On pok—les:
i
(Nara-, Oi Co„^Ci07) (In'umlicL CoInpan)'/l"Obc ?"tu11 n-) (FxpiFduon Dntc) -
j (Name or Conmaor) (lnsuznec Como_an)•iPOUM `unc:r) (—Ekoim6on Date)
(Name of Coluraaor) (Lnsuran (E%Pu' a6on Dam)
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(Nam: of Cona2mor) (Insurzacc ComrarryfPoLicy Numtr_r) t�spiruon D
I s
`I (atxsa 15��`•OC3 r c .irl)oo�:y-w C,Cu4 inform oo p�in::a6 to.11 ooc-_='O: )
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I (✓) I
am'a sale pr-opn.etor and bave no one worl,3ng for me.
j ( ) I am,a home owner performing all the work myself:
NOTE:pl=yc be awl is a..j,-_}c hcm=o,a to awl oy p='LOW w dO r• -=-,D c rrwaa work c�d�cV of
I one mocc Il_a Ctre=L-an,is uiich Lt'bomoow nc nod=or ea tSc pvunda�prrL the o LT we err-d-ai rn!e
c=VloY—uD?--e the..ui r �- -,,w Aa(GU152=I(S)1=pptintion by a bomco--=fcr a 6c--=a p---mn r=y n76=oe LbC
legsl—of ea e=Ployer ucda d3*worti.ala Comp,om.tioo ArL
1 I undcnand dsa a copy of thi-mttmem m -f be fo,n-dod to the Doq rto,c of lndussicl A�&r'Y Office or for the
cove roc wcrirelioa and!h_2 L-J=to so:arrc 1 ON—Ae^e taadC=K:,;oa 23 A of).tOL 152 as lcd to the i V016ca of cimisal pcaa-W(=
eonzi:!nS of a fine orup to 5).Moo.rtdfc”u��of up w ooc y-=r end civil pm�Yia is r5c foray or.Stop wort;Ordc and.
run of S 100.00 a d--y t pjcr t me
For dcy.rta+=�u+c only
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0Sr ?'�rep-" t.ot R x.
Signacurc of Lia=is=fPcmtictc=
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SECTION B--CONSTRUCfiION SERVICES
8.1 Licensed Construction S1upervisor: Not Applicable 13 Name of License Holder: C h 4 r )e,•s. CT. (J'M,9 S G S oz 0 3lo y
License Number
Z� La✓re( bkere-41 . rL DIDSV lL-a.y- LO64
Addres Expiration Date
Signature -- Telephone
"°� + rnpresatne Not Applicable ❑
114 3 V0
Company Name // Registratioon Num er
Char lv s 46 1N+C� 1'0/, 06
Address I/ I Expiration ate
Z� �Q✓re� /��'fl �/'. LP�rctC // Telephone
SECTION 10-WOR14Ef2S,tbMPENSAT10N INSEiUNCE:°#�iDAY1T�AA L c 952,§ 5C{6jj
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...... ❑
0M Wl� ER
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 1083.5.1.
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-vear 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
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SECTION'S-=DESCRIPTION OF:P.ROPOSEDVVORK Jchedk'al[ay0Iicablel'
New House ❑ Addition ❑; Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [ice] Decks [ Siding[0] Other[E
Brief Description of Proposed
Work: 4� k It ' deck
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
s ea s u�> tae�ctsao `sllractcDr�igletla` � nrt :
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
Rd (64 TO BECOMPE—I WHEN
OVtINERS AG;ENT 0i2 CONTRACTORPPLIES POR BUJCDINO PERMIT
I, DeAn v` as Owner of the subject
property
hereby authorize qr 1 f eS ko 1 e s
to act on be If,in all tters relative to work authorized by this building permit application.
ZX 2eo.
SignktyDa4f Owner Date
I,—C CI a r Ic S � i,f"La—s ,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. '
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Print Name
Signature of Owner/Agent Date
Section 4. ZONING All Informat-j6h 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 T 719. i
Frontage 1
Setbacks Front r/1 j - 9
Side L: ''' R:= L:! 40 R:` yQ r
Rear 1n
Building Height
Bldg.Square Footage % i f
Open Space Footage %
(Lot area minus bldg&paved I
#of Parking Spaces 3
Fill: € 1
s
(volume-Sc Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW qF YES
IF YES, date issued: i
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 DONT KNOW 0 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
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 ® NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
9ng�Northampton B Department
r -- -
212 Main Street
oom 100 -
» ' AFR 2 9 205jortharnoton; MA 01060
phone 413-587 ° 40 Fax 413-587-1272
APp1=��6I0N-TO�e@N LTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1,=SITE INFORMATION
1.1 Property Address: x � Th�secfio�a doe completed baf#ice
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✓1 C 2fverlajr�Discf
SECTION 2-=PROPERTY OINNERSHIPJAUTHORIZED AGENT
2.1 Owner of Record: j �^
Name(Print) w Current Mailing Address: .�
—PnA- �� .L,�, � Telephone
Si r `-`
2.2 Authorized Agent:
C a r i e s
Name(Print Current Mailing Address:
Signature - qt g 3 w C>%- YL`
Telephone
SECTION 3=ESTIMATED'CONSTRUCTION COSTS.•
Item Estimated Cost(Dollars)to be Official'Use'Only
completed by ermit applicant
1. Building Z SCJ( ldingPei-ThitFe=e
2. Electrical (b}:Estimated Total Cost of`
::ConstniL ion from
3. Plumbing .,Building.Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=0 +2+3+4+5) -Gheck.Number
This Section.FtiT=Offtc[AUUse'.Offly
'Building Permit Number- D"ate,,.
t ssued: �-
Signature: r
Building Commissioner/InspectordfBuildings - Date
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File#BP-2005-1062
APPLICANT/CONTACT PERSON CHARLES G HOLMES
ADDRESS/PHONE 27 LAUREL HILL DR LEVERETT (413)367-2826
PROPERTY LOCATION 642 NORTH FARMS RD
MAP 02 PARCEL 028 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out r
Fee Paid
Typeof Construction: CONSTRUCT 9 X 12 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:-
Owner/Statement or License 060364
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION P SENTED:
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 Perniit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
S
_Se tic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Stree ommission
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.