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I r v DEPARTMENT OF BUILDING INSPECTIONS � _ _
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INSPECTOR 212 Main Street • Municipal Building c>a�V=s v�'
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 his/her construction supo: ' 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, 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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itillet
4 6-,,,,„ of Noriliampfon
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`15' , "'.._,,...,47 ;•'. -.... ,--;7- ---:
DEPARTMENT OF DUILDI7G INSPECTIONS
212 Main Street ' Municipal Building di,
Northampton, Mass. 01060 -,,,,
WORKER'S COMTENSA'1'10N 11S UIZAN CE AFFIDANTIT
-----
I, iiii)fil_P E T 43(271,._E k14___ ._
(Iiccnst.f..../perinittcc)
with 2 principal place of business/residence at:
Y.Lipan70, Pa4/4) ta Cij___ES T7 E/ r/Eh. ____ hjAborie )3i/3--0,/ 4.-- cis-i./v
(sti-Licticity1:::.tilif:PLip)
do hereby certify, 110(1e1 1.11C pains 011d penalties of perjury, that
( ) I am an employer providing the follovdni.: worker's compensation covera:_i,e, for toy
employees working on this job:
-
(Laura_nc--..- Company) ("PcLic-f NtimE_y_.r) CE.):Dimtion Date)
,....--;
()‹ I am atsoie prOpriet.S11 2,C1.1erai C011=C101" or homeowner (circle one and liave luta
the contractors listed below who have the foilwin2 worker's COMDtrIS,21210r1 policies:
(Nc of Contractor) Cl.nsunc;i. C011:22:■yrP0117 Numbor) (31.y.tilr-,:tion Date)
(Name of Contractor) (Insurance Conat:ialiv/Pol.ic--,, Number) (Explranon Date)
--------— . —_-_-_---- -
(Name of Contractor) (Inostranc:_. Coma nyiPoliy Nttint-,er) ,.1:-.7.):F.-rarion Date)
(Name of Contractor) (Insurance Com7,a_ny,rPoticy Numbc.r) (1-1.xr,17,Ition Date)
(attach a.ciditioc-,1 iiCt
CX I am a tiole proptiet_oi rod Li have no c.)11:1,' v:orkinh for me
( ) I ten a home, owner Performing all the -,. o ..-c11'.
NOTE:pic-....s.c be=,,,,-,-,Lt1:,!,,V0ic, -,)I;;;,,p....--:-:7::-...:to 1.,2,--,,,.c,,Dr- Con or•',7;)a ir
no.t:pore than thrco Uniti If‘c-Lid/•,..b,1.,;,,,,:,...x,k-D.,-„-rt,i,...1,c,..,-c•xl tl. E---:....::-.^...3 z..7.-_dartzr•,-111)=-.7to alr n,.:..t cc,r_r ally oc..7.:::::•7::::'
CZ1plOyCZ3 1.):1;_ta-ther'.wc.:1,.. :c -:.--4:-.7:_-..-..a....icn Ac:(C.71-152.1.-z,l(5)t,r.r.c.1:2-a:ic.-.:-,by a hot:it-ow:xi.for a l.ce,...7..c c<-p1-5::::::-........,
Itgal lotus of on ccoploya-under 't.a6 Wcvice-11 C2..0.-up.or---....tion Act.
I u.n.dc..--tt,uad th,i a coy of(hi,rtattn--.--:rn.y ho forsvnt<1.<,--J to tl-n I)-.7.1xirtrnr.rct of Lod:us:n..1 Accv!...mts'Of5c.s of::,tra... r,for the
cOvcra.gc vcrifi .lipci And that failurc tot-..:,-.--1:::oo‘,...:Tr..;-c ur,..±-.:..;.c...11.ic..c.251 of 1...1GL,152 can lv.4.1 to(Ix impositim of cr:--ninal pc-nal:its
cooniatLig of I fin..,of up,0 51_500.0o 'co,,,,,,, .ir.:7)rin,x-rnnt of up to cr.-.yza.,-a:-.1 civil 1cruilic.3 in:1,c rof-In c.f a Sic:,V10r,::=rod a
fir of 5100.00 a thy Egf.in.-.1 ro:.
For 6.-47....runcztal ukc only
. .
.),gmiturt o.1 -cc:I! /) niitc,i 7;
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SECTIONS CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :!/-14/72 A S ,rr iaQ/4e J1 z., Q yo 9' 9
License Number
i
V3 D mon/ i. A•ID ?J CiiEs%F4t I EI,6 mg- 6 -cA 0-o 7
Address Expiration Date
/ „ - / ,_ A-
ignature Telephone
•....Re_ ,ere,.I orne'rrn•r.46 en`4'Contracto -F- - 'r°`.x ir;E.; t.* Not Applicable ❑
/am 0o i f /jam k-,- RLP4/ & I // ?OD
Company Nafne Registration Number
Ey3 mive,/i/ p0A i D RJ, C 11 t_ i i A 0 ed-
Address Expiration Date
Telephone y/,3-o?96-4--V
SECTION 10 WORKERS' COMPENSATION 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 121.
g
w %er uu o f n
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
•
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SEario.,, &DE :, PROPOS.ED4YIfORK(checkalf aDDl Ica
able)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors A
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: _ , �. � � , �
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes A.- No
Plans Attached Roll D Sheet❑
ou a.n• o,a8 �tioristo ezistin7housincot�p�etehefollowing:
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 Nc
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
• SECT;lON 7 OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERSS'�AGENt ORICONTRACTOR APPLIES FOR BUILDING PERMIT
I, ` _ / .��1- , as Owner of the subject property
hereby authorize Art, to ac; or
my bethalfti.,in all matters r=:ti e • work authorized y this building permit application.
4111 / ,'► 1 ,(
Signat e of 0 !.
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
maw
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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
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:
(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 DONT KNOW 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 there any proposed changes to or additions of signs intended for the property?YES_
No
IF YES, describe size, type and location:
�" s- c.,, fit :: tF ,„, - g5
---- of Northampton
` (L9 1 \V iiding Department nT s 6 . x , ,
�' 212 Main Street "—,r { , , r r
Room 100 Y
JUN 1 6 2005 &''.70-..„,1-. ."'":2.--.1.-k,4..,-;11-1,q � � -
N ampton, MA 01060 6 � � . �
L �._ * phone 43-587-1240 Fax 413-587-1272 k
LEA .,,'�, „ A5u1`
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
This section to,be completed by office
1.1 Prooerty Address: 4ft.w, 4-` r `, `s � `?
HOC
Map M1 -.7::,,.;-4!!!';'-1-7.''''''%-.:74,..--"-%1,..t.."_,,,. ...,,,7,', ° 't r Unit
J-,e /.�'
v„.c v
cM' J1'712/2 /5 I o-S .�
Zone ►erlay District
Elkm,S't.District ` ` CB DisMct
SECTION 2 PROPERTY OWNERSHIPJAUTHORTZED AGENT
2.1 Owner of Record:ELI- I /-,Q._ 6:1 ". Zej ille?,/le. e -----Vir. etio_L-11-5‘ #4 Na a Current M ' ng Add ess:
l 4 I se Teleph e •
Signature ` D/
2.2 Authorized Agent:,
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 ESTIMATED CONSTRUCTION COSTS 3yye
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a) Building Permit Fee
•
2. Electrical (b) Estimated Total Cost of
Construction from(6) _
Building Permit Fee
3. Plumbing
4. Mechanical(HVAC)
5. Fire Protection 6A/2— _ Od-5----6. Total = (1 + 2+ 3 +4+ 5) Check Number
This Section'For Official Use Only
Building Permit Number: Date'Issued:
Signature:
Date
Building Commissioner/Inspector of Buildings
122 FLORENCE ST BP-2005-1277
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 110-004 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-20054277
Project# 3S-2005-1706
Est.Cost:$2344.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Tom Boyle 111700
Luc SiL;;Iso. rw): x 07 0S Owner: EL1..IOTT RAYMOND S&CLAIRE M
Zoning: URA Applicant: Tom Boyle
AT: 122 FLORENCE ST
Applicant Address: Phone: Insurance:
43 DAMON POND RD (413) 296-4544
CH ESTERFIELDMA01012 ISSUED ON:6/21/05 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 2ND FLR REPLACEMENT WINDOWS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: i ;;:
Final: Smoke: Final:®K 7-/S;05 _I
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. V ,-'3
Certificate of Occu r an / / Si nature: .-------- --4,-,,,,>4.':',"1:1$
FeeTvpe: Date Paid: Amount:
Building 6/21/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo