38B-233 (5) �� f ,® Crzt�r of Northampton 1= =—Y =/.
it lt! iTlassacltusetts "!"
` '.r e. DEPARTMENT OF BUILDING INSPECTIONS , _' i
212 Main Street • Municipal Building '`-o
INSPECTOR '4 s,°
Northampton, MA 01060 .
o'
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as i,is'her construction sups:. ..:. or. 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, ...11 Aril/ understand the above.
(Home owner/resin a it's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date owo 3
Address of work
location
. •
€'i, Crzt�7 of artIlainpfoil I
s� ^v1► 4r . laaaxchctactta
moo• DEPARTMENT OF BUILDING INSPECTIONS __
212 Main Street • Municipal Building
•
Northampton, ?Mss. 01060 r'+
WORKER'S COMTENSA'I'ION INSURAI•■CE AFFIDAVIT
(]i ccnscc/p c-rmi t tee)
with a principal place of business/residence at:
------- -------------
(,hone )
(strccticity/ ta_rizip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am an employer providing the following, -worker's compensation coverage for my
employees working on this job:
- (nsurance Company) (Policy Number) (Expiration Date)
(f l I am a sole proprietor, general contractor or omeowner •ircle one) and have hired
the contractors listed below who have the following workers compensation policies:
(Name of Contractor) (Insurance CompanytPolicf umber) (Exp:rntion Date)
(Name of Contractor) (insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Inxuran.cz: Conlpain'y'/Polio' Number) i'xoration Date)
(Name of Contractor) (Insurance Comn«y/Policy Number) (Exptratiori Date)
(atiad,a.ddticQal s!xet eft:c.^char:to it !oho is 5 -,nonce::taiuir_,to ell eCc:-ado:•')
(V) I tun a sole proprietor arid have no one working for me.
( ) I am a borne owner performing all the :work myself.
NOTE:pleau be at.o;c that is iIc h<'e cOO cta u-So c: play tx s-co to r.)c.in■caanco,w..:n ctim cr tzpair t ott,c:.. tell ct cf
not mocv then thu co unite in tcf cfi t o hr-i,cvwun-rC3i,2-7-3 or cc O p .wa:ppurtcn nt therdo no txt grnerallV
c nploya-a ury c-r the woci;crs on czatim Ari(GI-152._t 1(5)),rppl:^ion by e hotnce vo o for n bone cc permit ma.y cvO n c t o
legal ctatui of an employee under the Worker'.Cocnpuuu.tion Ace
I underhand chit a copy of thi.statcsi:cnt a:.y ho focwnndod to the D ,ort ncnr of Iadrutriel Aecidrnt.e Ofliicx,of onourx for tam
covnigc vaificatioo and that failure to:xuro coverage w'4c.r section 25A of MMOr,152 can acid to tha imposition of mrnir i peratt:cs
ooesiating of a finc of up to S1,500.00 artl'tx i.cprisonzsc;it of up to on:)tar n cc civil pcnaRica in thx form of is Step Work Oril it,d a
find of 5100.00 a thy tgainst rno
For dcputxmCal u,c only
Permit Niunbe s
----------
Signature of. i��..� Jictn:;,.:_� i F
SiCT001V 8 C,NS.TRIu,TION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder : J`(AGLuYUI foie S t 001q
License Number
.., . .1.� s,� i • • 4 1-1z-7-1 ,S
Addres•, Expiration Date
/ . 20b06
1 ' /
Sign. ure Telephone
. _'ire ,u.ernen °,.n'rc or � �� `, � Not Applicable El
-
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 103 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
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 7)'te_. _ ._L
SECtION .. D a5 -7 0 F PROPOSED�WORKf chec 11 a• ' Ica .e A ;
..-1,0w--."7, e++wMl °". ;, .:1't' ..-"re +?at;K .'Ai uflW H xs 1. # t • ail, 11 .w,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other
Brief Description of Proposed Work: t' aC.e -1•t494.tr `i1
Alteration of existing bedroom Yes No Adding new bedroom Yes v No
Attached Narrative❑ Renovating unfinished basement Yes c�o
Plans Attached Roll ❑ - Sheet❑
OBI New ITOU a aril it d"diti iab eXisti taff sing, comp e�te" tt e foll.o "i_-`ing
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
SECTION 7a OWNERTAUTHORIZ-ATION' TO-BE COMPLETED WHEN
OWNERS AGENT,0_Rq.CONTRACTOR'APPLIES,FOR,BUILDING 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
eA-eye. E. , 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.
Tl e e
Print Name
Signature Owner Agent Date
r . _
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 •Aac - F1-a. ,/
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 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 17 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. Ar9 there any proposed changes to or additions of signs intended for the property?YES _
No
IF-YES, describe size, type and location:
r
S Ns - ',','4;..‘,,,:t4.7,14;° :City of Northampton aoms ' `?' K M ',. a ,t1 _$uildin Department C Gu /i
212 Main Street S e Se• tc lab'
587 1240 Fax lee�5r�tlW t s e o- ,, i i � ` t i
s ;
�!' Room__ Northampton, MA 0106
�e 413 272 P tlo i �M, 6 9trt
APPLICATION TO CONSTFIUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section,to be completed by office
— Map a Lot �� Unit
6-(v 0
0 1 M ,L�- Zone �, Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
5-10 �I.1‘4e'`T �5e. . Ac.V1 — —
Namer(Print) Current Mailing Address:
elephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item t�tirnateC C t !Doliar } to b: Official Use Only
completed b permit applicant
1 Building ,�5.QO (a) Building Permit Fee
2 Flec.rical __� (h) �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) Qty Check Number /1t ��
This Section For Official Use Only "`
�
Building Permit Number: �� / 6 O 7- Date Issued:
Signature:
-------- --------- --
Building Commissioner/Inspector of Buildings Date
File#BP-2003-1002
APPLICANT/CONTACT PERSON ACH THERESE E
ADDRESS/PHONE 56 OLIVE ST
PROPERTY LOCATION 56 OLIVE ST
MAP 38B PARCEL 233 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 4(71-1-
Typeof Construction:_REPLACE PORCH FLOOR JOIST
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:
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 Commi :
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.
1
BP-2003-1002
GIS#: COMMONWEALTH OF MASSACHUSETTS
:12,433 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-1002
Project# JS-2003-1605
Est.Cost: $500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 7448.76 Owner: ACH THERESE E
Zoning:URB Applicant: ACH THERESE E
AT: 56 OLIVE ST
Applicant Address: Phone: Insurance:
56 OLIVE ST
NORTHAMPTON MAO 1060 ISSUED ON:5/15/03 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE PORCH FLOOR JOIST
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 1888 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo