22D-070 (13) � O�'Ct1AMP�O
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DEPARTMENT OF BUILDING INSPECTIONS " /a
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INSPECTOR 212 Main St,eet Municipal Building
Northannpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as iris/leer construction sul The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or trvo fancily
dfvelling, 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
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 -71110
Address of work
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SECTION 8 -''CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder _ _—_.._._- --- --
License Number
--------- — ----------------- -- -------------
Address Expiration Date
Signature Telephone
9 'Regtsterea°Home Irri�rovement Contractor ,_.,,}_ „�,� ,,,�,,e��,, �„ ,, _� Not Applicable ❑
Comp-any Narne Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25C(6))
'Norkers 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...... ❑
MT
HoriiieA..� W"M,, emp ion
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(I) or two(2) fanniiies
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 LLiability 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 hd State of Massachusetts General Laws Annotated.
Homeowner Signature _
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SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition[] New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work_/40AelIe//0'�`Qi1 --
Alteration of existing bedroom -Yes _-v_. No Adding new bedroom _— _ Yes /No
Attached Narrative SAC ✓�s� Renovating unfinished basement __._____ Yes ��No
Plans Attached Roll [i - Sheet [i
6a. If New-h"odse`and'or addition to existing' houSinf7, Complete the following:
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
f. Method of heating? _ _ Fireplaces or Woodstoves _--_ Number of each
E, Energy Conservation Compliance. Mascheck Energy Compliance form attached?
n. Type of construction
Is construction within 100 ft. of wetlands? Yes _ No, is construction within 100 yr floodplain _ _,_Yes
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
1 as Cwner of t��ie subject property
hereby authorize to zc; o!
my behalf, in all matters relative to work authori7ed by th,s ildin, permit a�olication.
Signature of Owner
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.
_ ` --- ---
Print Name
Signature of Owner/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 N
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage �UOlJ %
Open Space Footage
(Lot area minus bldg&paved t� .-�G/+✓'-
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 the site contain a brook, body of water or wetlands? NO _ u0N'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
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:_ ___
patirytent:useo. ly �
City of Northampton Status of Perriilt '� 'ta �� .
Building Department Curb Cut/Drtvevray ermit
-� 4 � f <.
t[Aain Street Seer/Septi6A
vr VHbblitty ��� ������ "� ' � 2 `
p0tI 1 00 Water/Wel( Avallablilty � � ' �
- `n .VC I I t• ( T�toli, ��t1, 0 1 c6o T`"'O Sets of SttUCtUfai�P�a115 � � #
f 1 e r
e (-)il ,, l l�1 �lJ F a J 1 / PiOt/Site PIanS
- — AL v
7 Other Specify �3
APr'LICATI CfrJ}tSUCT, LTER REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
k_ s — — — -- — — — — --
SECTION 1 SITE INFORMATION
This section to be completed by office
f .1 Property Adcfress
G1 a 771�
p Lot_ Unit-----
---------_--._��_______,----- ---
Zone u/0--loverlay District _
Elm St. District CB District
SECTION 2_PROPERTY OWNERSHIP/AUTHORIZED AGENT -
2.1 Owner of Record:
CD
carne .( rinf) _ �! . : i ;ir ,• .._ "��`�' �
5'O'6
2_._2_ Authorized-Agent:
IG I�
CSECTION-3 ES TIMATED CONSTRUCTION. COSTS
.tee ost (Dollar ' i o: OifiCl l Use Only
I
•n�pleted by perrniit
ermit Fee
�DoD. Dd
- h n a Tnf l Cost Of
frotj) )
Building Permit Fee �--�-
I
5. Fire Protection
v_ Ufa'
eepw'06 --- Check Number
_ This Section For Official Use Only
Building Permit Number:__--,__— Q _ Date
Signature:
Building, Cornmissionet/Ins;.ector of Buildings pie
File#BP-2004-0028
APPLICANT/CONTACT PERSON LAMPIASI MATTHEW T&LISA A
ADDRESS/PHONE 86 FLORENCE RD (413)586-4421 ()
PROPERTY LOCATION 86 FLORENCE RD
MAP 22D PARCEL 070 001 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 /d
Typeof Construction:_STRIP,PLY&SHINGLE PORCH ROOF&CHANGE ROOFLINE TO HIP ROOF
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 FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 C ssion
2 oC�
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.
KE +�R1;A7CiJ BP-2004-0028
GIs#: COMMONWEALTH OF MASSACHUSETTS
I -,22D t?7Q ' CITY OF NORTHAMPTON
Lot: -001
Permit: BUIi ft
Category: BUILDING PERMIT
Permit# BP-2004-0028
Project# ]S-2004-0045
Est.Cost: $1000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group Homeowner as Contractor
Lot Size(sq. ft.): 15246.00 Owner: LAMPIASI MATTHEW T&LISA A
Zoning:URA Applicant. LAMPIASI MATTHEW T & LISA A
AT. 86 FLORENCE RD
Applicant Address: Phone: Insurance:
86 FLORENCE RD (413) 586-4421 O
FLORENCEMA01062 ISSUED ON.719103 0.00:00
TO PERFORM THE FOLLOWING WORK.-STRIP, PLY &SHINGLE PORCH ROOF & CHANGE
ROOFLINE TO HIP ROOF
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 7/9/03 0:00:00 1003 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo