36-313 (3) #1. ) a QLzt r of Narf1 &ntpton • ) _ _
r �v y 1 " , (� ` "Massachusetts _ ` =
DEPARTMENT OF BUILDING INSPECTIONS /
e. INSPECTOR 212 Main. Street • Municipal Building _ y
Northampton, MA 01060 S`' .
e
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as Lis /her construction sups .'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
I, kf-- 0 4 ), 1 ----- understand the above.
(Home o ner /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date ` /� --3 k /
Address of work
location / (2 , /2 Y1 _ r ,v,1 t_ 6L)!--A/
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, .5... D EP ART1v f ENT OF BUILDING INSPECTIONS . • .-7:- i '
212 Main Street ' Municipal Building ,
Northampton, Mass. 01 060
WORKER'S CONfPENSA'riON INSURANCE AFFIDAVIT
_
(li c-,-,n.s2initic)
\vitla a prin cipal place of business/residence
(plione___
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(strecticiity,":71.f,../7ip)
do hereby certify, titi(ler the palns and penaltie:; of _ jury, that:
...._
( ) I aria an employer providing the folio \vim: v;orkcr's compensation coverage for my
enipIoyee,'s working this job:
- ansurancz Company) (PcLic-; Number) CEI)rp i IT: tic n Dare)
( ) 1 a_ai a sole proprietor, general contiac or b o :al eowo er (circle one) and have hired
the contractors Listed below 'who have the fOlir,Z:Yir12, V.1(:)ikPS compensaldon policies:
(Narne of Contractor) (Lnsurance Comcany.Toticy 'Nu/Tibor) 1E, xp:ratacn Date)
(Name of CODITZCI07) (lasuranc:-, CompanyiPoNcv Nurfrfizr) (1:x1)i:ration Date)
, .
—_--
(Name of Contractor) (Insnir-ancz Cc nnpa.nyiPo I ic7 N am 'rr ) (Fxr.:rat2:oo Dale)
(Name of Contractor) (las ComanyiPoticy Nurnbcs) (Expiration Date)
(..,EL..,..i.i .6-litic,..1 ...-,-.t if 'cc,,sry :n ic.-21-_,', ';:lf-x:n.:ic,-. -,---.:::.:::::::;:..; ,i3 ::,: .1
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( ) 1 t.ita a pole )ropriet.ui arid have 00 anc -, :k.i11: - 4 for inc.
S il 1 am a 11011le ()Vine:" lie,17:C7I111flg all tL,:', ,.■.,;1:-.
NMI:: ple.zsc bc asswc that whtic 1 1.3 ;) L3 ,) :7 ct:-.trcr-,:scttlro or :rpair on
not Inc(o th_ throt titlita irt v. i ',I 1:ono.:r'a r2-7:o or cc thc E ct. • ...1 th.o. ace n.:..t ccoorally c...y,::
cploya- ur.t.c.HT the veorkr,-;:. c.:-.4:-_-_--...-..a.ticso i.-ct (00152m1(5Y), ar.T. by a hotncownor for a Lc cc p71::
legal rtatuc of am cairployec under tit', Wokee's Coozpaicro Act_
1 uncicrztand that a copy of this rtatcr...--...1 may bo for.v,trdo,i to t.ten 1) o f lothatalri al Accid--,ItY ofrioo of 1.,.....,,,,,, for th e
coverage vcrifi=tiCx1 :lad that failure vccatrc covr. IIIIC, c.cctio 2!" A et MCI, 152 can lcati to the imposition of cc pettallic
cocci:6 o f a. r o f up to s 1.3 an..2)r in.:prc.:It of up to or.-.. }-z..t.: ar.1 civil pcnahics in thc form of a Stc, Wo.ri•. Or- .^: and a
ft, : or s 'alai a dly LF,un....1 rry..._ .
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10/29/2003 18:00 4135292237 E B I- LhiBERG ASSOC PACE 03
MORTGAGE LOAN INSPECTION
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,„•. /. a BOOK 6703 PAGE 299 PORTICO
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CARDINAL MAY
To: Countrywide Home Loan
OWNER:
AND:. CnTIC Lepine - Wzorek Associates
I hereby report tbeat prbaLee shows on Sib *alb LOCATION: Lot No. 9 Cardinal Way. .
not loaded ands a flood Bawd Ana as dawn amtut Northampton, Massachusetts
Erman Ibis bhp, .
Odom* No, 250167 -0001A E. B. HOLMBERG &Associates
SCbotbe Aoril 3, 197, LAND SURVEYORS
I ahlo moot, b the bane day 14towlodp, i�adm a7 UNION S77t�T. EASTHAMPTON MA 01027 -x945
ad ballad(thatthia fospoodon pbal ohm die 77 D/1LiON loin ROAD, .o a6w otoe2 0176
Mi wov n at or improrwwob a loaded al thadadra
deeodbod, dot flat iaproorsoan aA wM6.ly of
1b . Ind lot fin woad ancrodionatz voodoo . o f y . , 1 " • 40'
pagoda *imbed by to Iwamoto. data �pipiq dsosoaoept a � & EMI `
mad that Gam WOmanledt the MREpQ DATE:
ttootshows ha>rooa�araptasranot i o H rr3 v October 27, 2003
/ ,/ ( .1 \ i 4 tsN � `' , ��oq' JOB NUMBER: . i o: 03-347
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T 1* PLAN IS POLIDENTIl1CAT1oN PURPOSES ONLY AND DOES NOT COMMUTE A P O!'1117Y SURVEY.
Alib14N0'P roaccairmwrioN PI.ANIONO Letyotrr.
Nash Home & Leisure: Sheds Page 1 of 1
I Ox*WOOD GABLE
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SECTJOPtS CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
Re: ere® g. iime veiren ontaac r Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTIOH1.O WORKERS' COMPENSATION INSURANCEAFFIDAVIT (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 ❑
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1 kfi 024 � eras g.
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" c-rtifies and assumes responsibi , for compliance with the State Building Code, City of
Northampton Ordinances, St. e . d Local Zonini4_o :ws and S :t• • ssachuse is General Laws Annotated.
Homeowner Signature e/C,L _ 1
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?SECTI-ON5* DESCRIPTtfON OF PROPOSED WORK (check all °applicable) t dg
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg_ Vi Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: SNCA TAsAtkA .A Con io'PC 2 -o
Alteration of existing bedroom Yes V No Adding new bedroom Yes V -No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 • Sheet 0
6a01Age TOMVI TOTIaddi ionito ezisting"fMing comp °te: e l e followin
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. Mascheck 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
S 7' �OWN ER 4 AUTHORIZATIO N TO B E C OMP L E TE D : WH EN
OWNERSIAG
TOR CONTRACTOR APPLIES FOR BUILDING °PERMIT
I, ,`i -- , - II , ' �7 ' )v , as Owner of the subject property
hereby . horize ,/t1 S,LJ //4/L to act on
my •-h. , in all r aters rel. .o work authorized by this building permit application.
1 p
Signatur: of Owner ate
�. -,
i, , 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 1 5P-! 0 156 .1)
Frontage
Setbacks Front '43
Side L: R: L: R: I� /D
Rear
Building Height
-dg. Square Footage N(P1 %
��
Open Space Footage
(Lot area minus bldg & paved
parking)
# of Parking Spaces l
Fill:
(volume & Location)
A. Has a Special Permit/Variance /Finding / ever been issued for /on the site?
NO DON'T KNOW V YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW t / YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT 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 pere any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
,
1
_ ate^ 4
i!City,,cif Northampton - . a
, _ Buil ii1 Department �� � � -': �'� �� �
212 Main Street . �. �
Mt q , 2 3 C;, 4 Room 100 iT; -. ' � � A
Northampton, MA 01060 a F a _ � • P �, 1 '
,' 8 ' n ' a qk ' '� .1
phone 413 - 587 -140 Fax 413 - 587 -1272 J 4
is, � , ,, 3t � 4s':� h .. � � v � z
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
1.1 Property Address: - Thissectlon to be complet ed by office
\V\ \ cre L %S r ., i
Zone ` Ovelrlay"D1
V 2 . {A Cam: iv\ C, `0 10 C- ?
Eim St DDistrict ': ` * CB District ;
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZ AGENT
2.1 Owner of Record: R
i'�i4 ,, ^, d�N C `c cJ z_(A s d C y n� 1� %C... Y ob k_ - 1 (0 `1 CP C:.D i e4 A L. VJ f V A.5 � .-e ,i �1- M P e t G Z
Na (Print Current } Ad rt — t V2 3
PX . Telephone J
Signature
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3' - ESTIMATED CONSTRUCTION COSTS jJ 0 -r u GL N i
Item Estimated Cost (Dollars) to be Offic Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
S H k_fl Z1 D G
2. Electrical (b)'Estimated_Total Cost of
1
'J " Construction from (6)
3. Plumbing 1 fr Building Permit Fee
4. Mechanical (HVAC) Ai 'P
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) , >77(/U Check Number 99g p
` This Section :For Official Use Only
Building Permit Number: e �(f Date Issued:
Signature:
Date
Building Commissioner /Inspector of Buildings
File # BP- 2004 -0904
APPLICANT /CONTACT PERSON PENZIAS DEBORAH & CYNTHIA ROBERTS
ADDRESS/PHONE 169 FLORENCE RD FLORENCE (413) 587 -0883 Q
PROPERTY LOCATION 169 CARDINAL WAY
MAP 36 PARCEL 313 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 9 �lff �t7 p ,, ,.
Fee Paid
Typeof Construction: ERECT 10 X 20 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
i, /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 C�o�upis� ion
, 77,777
' .. "®G'. tom'
3/7-c/ie -
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.
-4
169 CARDINAL WAY BP- 2004 -0904
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36 - 313 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: shed BUILDING PERMIT
Permit # BP- 2004 -0904
Project # JS- 2004 -1349
Est. Cost: $2700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): Owner: PENZIAS DEBORAH & CYNTHIA ROBERTS
Zoning: SR Applicant: PENZIAS DEBORAH & CYNTHIA ROBERTS
AT: 169 CARDINAL WAY
Applicant Address: Phone: Insurance:
169 FLORENCE RD (413) 587 -0883 0
FLORENCEMA01062 ISSUED ON:3/26/04 0:00:00
TO PERFORM THE FOLLOWING WORK: ERECT 10 X 20 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 3/26/04 0:00:00 948 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo