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DEPARTMENT OF BUILDI7tG INSPECTIONS L'
INSPECTOR
212 Main Street • Munici�ll Building ��� s<•`��
Nordiwnpton,MA 01060
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<z:.'ssor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be,a one or two famil--
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 fortlie City oTNorthampton wants-airy 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
de
I, �iA���� d� 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 lu r 4 G vu ar 1 e
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•A} `e (riff �f �{arfl�aiit}�t�)� _
j 4 DEPARTMEIJT OF BUILDD-,,C INSPECT(OI.'S -
j 212 Alain Street Municipal Building
Northampton, ATass. 01060
WOruc.I ,S COL'CPI;NSATZO.N 5NSURA-N CE AF70)A.�'Z�'
j
(li Ccnsxlperml ttcc)
��1C11 a principal place of businessfresidence zt: — ---
(str t/ci ty1na.tc1D P)
do hereby certify, under Lhc pains :.nd penalties of per3ury, h.l
I '
I ( ) I am an employer providing the followine',.:,orlcc>✓s comocnsaoon cove ale for Inv
emplovec:s `vor'`dng on this job:
I
(LgSUranc Conr zi.) (Polic-,NU_—ZDccr) (`;'plratior. Dal:_)
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I am a sole proprittor, general contractor o homeowner ciz one) and have hired
the cone aCgrs listed below crbo hive the foilo.vinQ workers cooptn_udon pokies=
•Z_2ajvACL_ ( L BOX 205 o M 0>o4.L_� ! •5.31 319
(NMc Of Co- ^Cior) Cotnpa l}- l 04y �"LL 1L<:) fr'-JIiJ Date)
I
— (N ne ci Contraor) (lrs�ranc: Comoanv�Polim, Nuncrr) (Lxpirtion Date)
(Name of Coturaao:) ()nsuran.c: Company/POLcy Nu bar) (E-xpirdoo Dalc)
(N2MC of Contractor) (Laa=c-- Comcany/PoUcy Numbu) (Expi-,6oa Dais).
(aasb ad1.-'.00,1>'xC,if ncocs.�-ti•to iacud_ialonau o°pcta:n;as to.!)
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( ) I am a sole"pl-oprietor and bave no one nrorL-ing for me.
am:a home owner performing all the work myself.
i
NOTE:plese be cwz=t4,,.M-jzje bcmmvvcn w'bo employ peom to do rya's-ark ca a d,,,U--f,of
not meet tiL tfsu_-tni'J in c•'sieas the bomoowoc rcxida a m the�a>��P�-=tbes,v t-c oot�-.�.:.11y oa:^d.-ai to be
ei�ploycs and:the A=(GUI 52-=t(S)1 a pplin oon try a bomco oa fc a 6c-• -or pa-=h I=y e.-id el:c
lcga.l rt=^,•or ea loyx uodm dt Wocic cl.Coc=p.,ti Aa_
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tb.a a Copy of tbi.eu.ammi m..y be foe- _,J-d co eba Cp •ae,m°r 1,6,,r;e!ne dea. o(roa°r 4a+�.00e for tb.
eovexe^c"eircaio°aad tltt L-iltae to seuuc`coke .. -.;oa 2SA of MGL 152 c=ted to the=pozibco of—ia.l pcaxW-
oo=-`':3 of a fine of up to S 1}00.00 mndfor =pr,�o=�=orup b C=y-_r aad c�-il pca.P.ia i°the form of.Ssop Work Ord-_ and a
F=of 5100.00.day.pin:a t>x
t-crrmt Nutnba- ---- —
✓� Lot rt
S;paaszzt of Licu�/PccmiucG _ e I A
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SECTION 8 CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9�lteaislerec11011is�tira erertlltrattE a ti 3 Not Applicable ❑
Company Name Registration um er -`-
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION`tNSURAHCE.AFFIDAVFf`(I '.G:L c.152,;§25C(Sy}
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...... ❑
�4ffi
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 1083.5.1.
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.AAperson 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.
/FIomeowner Signature
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition F--j-'. Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [O] Other[0]
of Description of Proposed
?VVork: TnS4et 1'1 o Bove QY(Mhci 9w1�Ntm N 4 Pub 1 - Size 21
_ ._ J
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. €1Cev� ra�ise am ad�t�ot ` xsincosicl:ccirtaeth IfoF�aulg:
I tag�f hi,Minn•One Family Two Familv 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 AUTHQRIZATiO,.N 7G BE,COMPLETED? WHEN 11
-OWNERS AGENT OR'CONTRACTOR APPLIES F6R.BUILDIN'G.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
l � dA ,rf 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.
iL-7Je4_n6r A61I 42 N
Print Name /
Signature of Owner/Agent Date
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
Lot Size 1
Frontage --
Setbacks Front ' 175 772r,
Side L:! R L:7�6 R:_�f
Rear
Building Height ;
Bldg. Square Footage j % 3
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 DONT KNOW Q YES 0
IF YES, date issued:',
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
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 Q Obtained Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location: i
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO
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 , NO
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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�� epaetol �
` \ City of Northampton St1rfP 1 � x �
wilding Department , waP
6
.212 Main Street
Room 100
Northampton; MA 01060 Sets�t Ct?tans � �
phone 413-587=1240 Fax 413-587-1272
, ?a 14CATION'TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
-
SECTION I SITE INFORMATION
1.1 Proaerty Address: Thrs sectron to be completed bx pfftce
G-vt. 0 LaV►e Ailapr
��y�e nCC, I"r� Zone � � Overlau Drstrrcf
010 6
Etrtt D�stnct CB��stnct
SECTION 2-PROPERTY OWN ERSHIP/AUTHORIZEDAGENT;
2.1 Owner of Record:
��l klor 5Yt�DN �� 6/'ejakZ LhG l-�rtrtl ei?ee Nj /11060�-
Name(Print) Current Mailing A res :
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. Building sa, sue' (a)Building Permit 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) Check Number
This Section For Official Use Only
Date,
Building Permit Number.- Issued:
Signature:
Building Comm issionedinspector of Buildings Date
File#BP-2006-1182
APPLICANT/CONTACT PERSON ASHTON THOMAS L&ELEANOR
ADDRESS/PHONE 28 GREGORY LANE FLORENCE
PROPERTY LOCATION 26 GREGORY LANE
MAP 29 PARCEL 531 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out —
Fee Paid
Typeof Construction: INSTALL 21 X 52 ABOVE GROUND POOL
New Construction
Non Structural interior renovations
Addition to Existing
Accesso_n'Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN 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 Pemiit 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 o 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.
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BP-2006-1182
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2006-1182
Project# JS-2006-1742
Est. Cost: $3380.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10105.92 Owner: ASHTON THOMAS L&ELEANOR
Zoning. URA Applicant: ASHTON THOMAS L & ELEANOR
AT. 26 GREGORY LANE
Applicant Address: Phone: Insurance:
28 GREGORY LANE
FLORENCEMA01062 ISSUED ON.•51512006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 21 X 52 ABOVE GROUND POOL
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 5/5/2006 0:00:00 $25.002307
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo