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DEPARTMENT OF BUILDING INSPECTIONS " l
INSPECTOR 212 Main Street ! Mui icipal Building
Northamptom, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as !Js/her construction sul :-: 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
dtivelling, 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.
(Rome owner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me..
Date S
Address of work
location q� rte , ��K� �f
�� a Crzi�r of NarillmilpfDll
Z
B - B ��RSIIAC11it5CIIE' _?
m DEPARTMENT OP BUILDING INSPEMONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 `
WORICER'S COMTENSATION INSURANCE AFFMAVIT
(liccnscrJpermittc�)
%vith a principal place of busMess/residence at.
t 1^'t'--KAILL-_�'� ���/��E►
(strcct/ci t}'sta��r�p)
do hereby certify, under the pains and penalties of perjury, Olaf,-
( ) I am an employer providing the following, '. orkel's compensation coverage for my
emplovees wor46ng on this job:
(Insu c- Company) (Poiic;Number) (E--pir-ation Date)
( ) I am a sole proprietor, general contractor o hameovvner (circle one) and have hired
the contractors listed below who Have the foilo 'ng wor ers compensation policies:
(Name of Contactor) (Insuranc; Connoa-,-yTolicf Number) (Expiration Date)
(Name of Contr<.ctor) Date)
(Name of Contractor) (Insurance Cornj;"myiPolicy Nusntxr) r�.xp;r t:..n DaIc)
(Name of Contactor) (Insurance Compa-ny/Policy Number) (Expiraion Date)
(attadt ui�±itionil slk-et ifnc�e:s�:::n i�c};:`c i:_:.Kr:u:ioc:��:aia:r_;•..�eJi<<:-ad�v•)
i
i
` ) I aill it sole proprietor <_Ild have no one ,.or4in for ale.
x7�/J 1iI1 a 110I1]e Ill rile
NO"rE:plc-sc be at\-arc lYtat 4 ]c k cm�ti1rr1 +tn c play o c'. r: :ainct arr r m OF rtpair 1:1'-11i:.�c.
not UK'CZ ih:n thcuo unity in\�i:dg,the k .1 c«rrs rca:d: cr a:tlu c_tiAS zprurtcc l thacto e:c rxX ccrrrilly occ• :c::rca
catploycl ualer the work'-I's mr4"csttica Aci(GL152"1(5)),rgTL_:;icn try a hortcotNncr for a Eccnx cc pcs:r:i:n:r.v
ICS11 ctatux of an a--Uployer under tha W,,JCCrt Cornjxrnxtion A.J_
I uadctstx•ad that z copy of flux date -ui nuy bo forwnrdl i to tbo L:,tn of lndirs d Amdcnt�Ofr] of Ia:uracJCO for rho
coverage vc ificsiioa and that failure to=-curt covcrago tudcr section 25A of MOO,152 can Ic_d to tha intpos-lion o(crin n 1 pccall:-
coali-.a ig of R fimc of up to S 1.500.00 an1'cx i Cprisoamctit of up to crx-)C-r and civil pcnxtlia in dY form of a Sicp Walt Ord----d a
fine o(S 100.0(1 R day igidwA ttr_.
-- Foc cjcputnYrYal axe ex:ty
' '" , Permit Nttmtxs _ -----
'
°SECTIONgCONSTRUCTyION SERVICES
8 1 Licensed Construction Supervisor: Not Applicable
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
�Re �reN meimpr u'e"inentFContr'acto Not Applicable '1
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 14 WORKE11SNCOMPENSATION 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...... ❑
x Rn€
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 _ �•
N , in S R T10 OF PROPOSED WORF(t cFi`eck�all
New House ❑ Addition ❑ ReplacerrV Windows Alteration(s)X Roofing ❑'
Or Doors A
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding Other [ ]
Brief Description of Proposed Work: t2 ��^ in/ L K-
Alteration of existing bedroom Yes No Adding new bedroom Yes _ No
Attached Narrative❑ Renovating unfinished basement Yes _No
Plans Attached Roll ❑- Sheet❑ (M 0 U-1("
6� IfNe "ho�ise nd a atld"it-iontoexist►ngh uo s'ine; complete #hefol.Loin :
a. Use of building : One Family X Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? P Y - �- 6 r ek"-'e j
d. Proposed Square footage of new construction. 7,)// Dimensions
e. Number of stories? 1
f. Method of heating? 01 L- Fireplaces or Woodstoves NO Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlands?--X—Yes No. Is construction within 100 yr. floodplain Yes'�,(_No
j. Depth of basement or cellar floor below finished grade 7
k. Will building conform to the Building and Zoning regulation ? Yes No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a 'OWNER)AUTHORIZATION' TOBE COMPLETED WHEN.
OWNEFtS A ENT`¢OR CN tq aw:W1 pPPI_IESkFOR,BghLDING-PERMIT-
as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, j�„i N11JJ ga = 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.
<JG 1�1�4 0V1Y a'1,
Print rJarne
_ S1�/03
Si 0 f Owner/Ag nt 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 ,•f �C
Frontage 3 6
Setbacks Front 3
Side L:_J�D_R: 3 L: R:
Rear
Building Height
Bldg. Square Footage
1-OA I2� 0
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces G �-
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: 3�12�(03
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book 'lwy Page It C and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'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:
/ 34-1
City of Northampton
Building Department Ctyrb x'
212 Main Street
r Room 100
- Northampton, MA 01060
,phone 413-587-1240 Fax 413.587-1272 Plo/Site- n
API!iJCATION TO CONSTRUCT, ALTER REPAI , RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECT40N 1 - SITE INFORMATION
This ress section to be comp
rty Add leted by office
1.1 Prope : �3 �f
1� 3� a
Map lot Urn S E
Zone Overlay District`
Elm St. District CB Qistrict
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
221 Owner of Record: R A
Name ,'rin ) Curre t Mang Address:
��t �` ' -
__ — Telephone
Signature
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
com feted by ermit applicant
1 Luiiding
O 0,0 (a) Building Permit Fee
2 FI ::.rival (b) ,timated 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 Only
Building Permit Number: Date Issued: —
Signature:
------ -- — --
Building Commissioner/Inspector of Buildings Date __
File#BP-2003-1000
APPLICANT/CONTACT PERSON HUNTER JOHN&SHEILA
ADDRESS/PHONE 17 LONG PLAIN RD (413)548-1027 Q
PROPERTY LOCATION 245 NORTH KING ST
MAP 18 PARCEL 005 001 ZONE HB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 7 7
T_ypeof Construction: REPAIR INTERIOR WALLS&DEMO GARAGE(NO UTILITIES)
New Construction
Non Structural interior renovations
Addition to Existing
Accesso_ry 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:
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 ssion
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.
«. f
BP-2003-1000
w ulM
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: BtJU ft
Category: BUILDING PERMIT
Permit# BP-2003-1000
Project# JS-2003-1603
Est. Cost: $24000.00
Fee: $85.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 57934.80 Owner: HUNTER JOHN&SHEILA
Zoning:HB Applicant: HUNTER JOHN & SHEILA
AT. 245 NORTH KING ST
Applicant Address: Phone: Insurance:
17 LONG PLAIN RD (413) 548-1027 (�
AMHERSTMA01002 ISSUED ON.5115103 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR INTERIOR WALLS & DEMO GARAGE (NO
UTILITIES)
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 5/15/03 0:00:00 177 $85.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo