16A-020 - r , ,./
� f:7(
)--fr"'Ij2- \./
4 _
•
( KAMA') ,
(City of Xortfiantptart
vrol
DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municipal Building ', Northampton, MA 01060 4 s
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his /her construction sup - :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
[LL` l 1 - understand the above,
ome owner /resident's signatu requesting exemption)
I will call to schedule all required buil ing inspections necessary for the building permit
issued to me.
Date )q •01(l
Address of work
location
‘!1*. i12 of Aitirillailipton
•
�� y11 E �Ia,ari - -•
:?e , —
DEPART1.1ENT OP DUI LDfrC INSPECTION'S —'
1 \ —
212 Main Street • i\ unicipal Building,
Northampton, Mass. 01060 to '
WORKER'S CO -6NSURANC1-_, AFFIDAVIT
•
(li ccnslpermiti)
with a principal place of business/residence at:
{phone:')
(so- „_..t/city /szat izip)
do hereby certify, under thc.pains and penalties of perjury:, :hal
( ) I am an employer providing the followinci \."orkcr's comocnsadon coverage for my
employees worming on this job:
(Las C orer --n') • (Policy Nu aber) CE pircion
( ) I am a sole proprietor, general contracor or homeowner (c c:e one) and have hired
the conrrac listed below wbo have the follow worker's coDDen adon po!!cies:
(Name of Con' ac or) (Insurancc Company/Policy '! .cr) (Expiruuon Datc)
(Name of Conorzclor) (Lns ranee ComnaayiPoLic- Number) (L »ir,:tion Date)
Name of Conrractor) (Lnsuranc: am- plo Nas.l.cr) (Eypimdon Datc) I
Name of Contractor) (lnsuran Compaay/Policy Number) (E.pirdoo Daic) .
arc1 (arormoo p r azains in .L cocae.ora)
( ) I am a sole proprietor and have no one worl;3ng for me.
( ) I am.a home owner performing all the work myself.
NOTE: ptcsc be c wy rc t4 *...1. J bcmcowccr o.to unploy pc to do Cori oa + Q••T ^� or
an( mcce tla.= t tmrr is w th the bomoownc rend. « ca the l - ouu:, wpurtcor_ Oct C-�. --+ley occ'u -ni to tic
cnployy -3 undo the .,cam: cccopc. sic Ac (GL152 t (5)).:.pplinrioo by n bomcoava fcr L c _ a pe"Init ray ctid'acec arc
l cp,1 n of no c cployor uadcr t1, works!% Coo,poc na
[ uo.dcranod die... copy of Si t. mi.coocc m.y b for-xw-cl.rd 10 t>o D p.nnscoc of A o.dm, 0l5oc of rra,nooa for t °
cover's% vv— lacuna read tau Ci1ta-c to socurc'covera under oeiioa 25A of MQL 152 no 1c4 to the impo,itioa orcimia.:1 pea,ltia
comi:.r:g of a C of up to 51,400.C.0 ardor ecolorioocroocrmt of up to ooc yc_r cod c.iJ pca..tia in do focal of: Stop Work Or nod
fun of S100.00 , thy tp .n me
^ For 'c,. ,s•rtm� -�1 u.c only
P ci mJ1 !`t t:ID DCJ
V 41/4/41 V ���� -- � t
S L6.1 01/2: of Li�as�JPcrmicic
t� - J g:
SECTION 8 - CONSTRUCTION SERVICES
1 + ,
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9...Reg stereit;Horiieiiiiitcove'ment. Contractor; ,; r, , ,, RA „ Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
—
SECTION 10 WORKERS' COMPENSATION INSURANCEAFPIDAVIT(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 ❑
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- owna-parcelofland 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 � Maassachusetts General Laws Annotated.
{
Homeowner Signature C `^ " ` — 67(t" 11TH
I SECTION 5- DESCRIPTION. OF PROPOSED. WORK (check _alI pplicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) r\ --7(6 '
lteration(s) Roofing n
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding [O] Other [O]
Brief sfrri t'�° of Pro o e d �
` C t � � I � .� p � "" A�
Work: , � cti 1�� p'CL L 1 fir) ��� p t y) v-e L' h' � f �^'y
Alteration of existing bedroom Yes No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll - Sheet
sa_If tiiriase' ardoadd�tiotaez> tsfkngk .iiuscrgx,calpetFre�[t�ic:
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. BE COMPLETED WHEN-
OWNERS.AGEN TOR,' CONTRACTOR; -APPLIES FOR BUILDING PERMF
, 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
, 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.
P nt Name
Date
•ig ature of�wner /Agent a
Section 4. ZONING All Information 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 f
Lot Size _ _____.__ • _________ _ _ — ____— _--
Frontage - - - -- — - - --
Setbacks Front
Side L: - -..- R: L:; —_ R:
Rear -
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg & paved
parking)
# of Parking Spaces '
Fill: _ i v i
(volume & Location) -- `
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DON'T KNOW 0 YES 0
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 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission? '
Needs to be obtained Obtained 0 , Date Issued: _ `
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO 0
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 Q NO Q
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
De rlment.i etoniy
City of Northampton Statueu1Pe efts a
E- sc.
Rijilr inn Department i^ 4 :' ifLl7rnrnura Pk4It : � �
12 Main Street
Room 100 ,Dater ella'flya 1, 4 r ,-
T 2006 NQ Campton, MA 01060 1,vci iiiia ik. r * ` ` . rt
C V I 2 p hone 41,3- 587 -1240 Fax 413 - 587 -1272 PIa�Site *F�Pats
l Oth S`peei ...w. F .. ,=' x
r ; A
t 't „,IrLICATION`TOd uCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION.1 - SITE "INFORMATION
= Thissec to be °completed by office
...::::, 1.1 Property Address: 1 L�-I V Y�� V I C P✓ M ap � r =ots 0 ' Un . . , (4
Leeds i 01053
Z �� ; Overray Distnct •
El S Dis , ' r "`. CB `Distr ct .
SECTION 2- PROPERTY 'OWNERSHiPiAU T H:ORIZED•AGENT
2.1 Owner of Record:
EsrA -/€ of Rama -LO '001)P� 136 SoatL, w�a',A S-)-- F1 �� IA4 OA �`
Name (Print) Q Current Mailing Addres
./ ‘ t Lw .h" Telephone
Signature
2.2 Authorized Agent:
\ k , , L. L ■ ) C • C. a fu-L. I L X c (u t o t ti \ %(. s,...s l i , 1 014 14 F ) M4 %3, O L
Name (Print) Current Mailing Address:
6\ .z_ , -k 13 5 py• `jb�
Signature Telephone
SECTION, 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building ` =(a) BuildingPermit 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) 0 0. D� C heck Number /, ) �—
J This Section For.Offic On
Date
Building; Permit Number. Issued:
Signature:
Date
Building Commissioner /Inspector of Buildings
304 FAIRWAY VILLAGE BP- 2007 -0458
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 16A - 020 CITY OF NORTHAMPTON
Lot: -034 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2007 -0458
Project # JS- 2007 - 000673
Est. Cost: $25.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): Owner: COOPER HEATHER
Zoning: URA Applicant: COOPER RONALD E
AT: 304 FAIRWAY VILLAGE
Applicant Address: Phone: Insurance:
136 SOUTH MAIN ST (413) 584 -7603 0
FLORENCEMA01062 ISSUED ON:10/20/2006 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE FIREPLACE W /PELLET STOVE (USE
EXISTING CHIMNEY)
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: Date Paid: Amount:
Building 10/20/2006 0:00:00 $25.00118
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo
304 FAIRWAY VILLAGE BP- 2007 -0458
GIS #: COMMONWEALTH EALTH OF MASSACHUSETTS
Map:Block: 16A - 020 CITY OF NORTHAMPTON
Lot: -034 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2007 -0458
Project # JS- 2007 - 000673
Est. Cost: $25.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): Owi wr: CoC: Ea i' .. _ .:ti
Zoning: URA Applicant: COOPER RONALD E
AT: 304 FAIRWAY VILLAGE
Applicant Address: Phone: Insurance:
136 SOUTH MAIN ST (413) 584 -7603 0
FLORENCEMA01062 ISSUED ON: :10/20/2006 0:00:00
TO PERFORM THE FOLLOWING WORK: REPLACE FIREPLACE W /PELLET STOVE (USE
EXISTING CHIMNEY)
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 S ! G — 5 t..
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. ------° --€:''''
Certificate of Occupancy signature:
FeeType: Date Paid: Amount:
Building 10/20/2006 0:00:00 $25.00118
212 Main Street, Phone (413) 587 ? 240,1 o.x: 013 S 7 -1272
Building Co' iss : Al: , 1 : i'