29-546 (5) ej� okoI
O��tIAMp�Q
�I II H'S5ACh1i5ttt8 � '
s
•� DEPARTMENT OF BUILDIJ�,'G INSPECTIONS
INSPECTOR
'212 Main Street • Municipal Building
Northampton,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(.•,•i sor. The state defines"Homeowner" as, "'Person(s)
who owns a parcel on which he/she resides or intends to be, a one or twofam"ry
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 r'.egulations. 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, P.-{ derstand the above.
( ome owner/ esident's signature reques g exemption)
I wil-1_ Jule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
r
a
20 aG3 0
C
E rii� �f Tariljaiiiptoil
A E .51 casxctlnrctta' _
Q DEPARTMENT OP BUILDf,\,G INSPECT101"S -
212 Main Strcet ' Municipal Building
Northampton, Mass. 010GO
- WORICERIS COIATENSA'MN MSURA_N CE A17FMAVI-1-
(lilperrn�ttcc)
with a plzncipal place of businessfresidence at: — -- -
_(phone!)
(su�I/dty/s atr/Dp)
do hereby cerdi -, under thc.paim -,rid penalties of pegui-, h:i
( ) I aria an employer providing the followinL'«orl:ei's cotnocnsa:Jo, cove age for 111)
emptovecs wortang on tluS job:
(Lnsur�c Conr;�.) (Polio:Nu- r) -- (r:-pirraorr Dat".)
O I am a sole proprietor, general contractor or homeowner (c cie one) and have hired
the con-aciors listed below wbo have the follolvmi g workers co�oer>_��on policies:
tr+fllIl:
0, Con.=10r) (111Rr3nc;. Corrloanyi"t'oiic; Datc)
- (Name of Contractor) onsa=c: Comoaz-vipol.ic; Nuncrr) (Ea-Du Lion Date)
(Name of Con>ractor) Gwar-anc Compa.n}'/Polio}' N:urbj) (Expim6oa Date)
(Name of Contractor) (insurancc Comcauy/PoUcy Number) (E."P'u-,6oa Date).
(aa�.ch addit-'oe,1�ue:,if nceazr}-w a�cv�-iaforn.�,�on Peuinin.s to all
O am'a sore proprietor and have no one worldDg for me-
(V� Iam-a home owner erformina all the Ivor-
p � )` myself.
NOTE:plea be earrn tfi••v a to hcmcovvm to cmplay pc-so=to da � s c oo e rtCP27 work M a d-%c11_ of
ant mete than L! o_cmr'Ll is«-bich the bomoowuc raid=cc oc the pvua6 zapurtca:rs tbcen na C=)rXy acrd.-ai to be
tairplor—unLe the--ka z=-ti-_..on.An GLI52-=1 5
t ( ))�=-PPliaboo by.6omwava rcr-iic�_or perma may tf:c
Icga1 n=^,•of as er�rtoyac under dao W-+S ea COrapamaLiOa Act
[uadcTt od tbd a oopy Of thin car—may ba f,—,td d to tbo poputmmt Om_of lr:a+rznOe foe tb.
covtr'-Fc`rcif t=iOO AM ttu L•ilrzc to 100='00% Cc undcr 10�00 21 A of 1.(OL 13'1 can led to the i=posidoa of aiminA pea We
corm:z of a fine of up to s I}oo.00 aad/oe of uP to oac y=r=d civU pcaxtJa to 6c fatal 0(a Stop Work Order and a
fix=Of S 100.00 a day tpjnst me
For u+c only
Permit ritunbes
0 i dap: Lot
Sitnaturc of Li crmiucc e J
1
SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9S2ears"f'erecl1ff—8- tie Irs y veme lioi ffic o Not Applicable ❑
Company Name Registration um er –
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAYFT(M.G;L.c:
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-vear 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 offlassachusett s Ge eral Laws Annotated.
)LOmeowner Signature w
�( r
j
•
SECTION 5-DESCRIPTION OF PROPOSED WORK(check-all applicable)
New House Addition ❑:;: Replacement Windows Alteration(s) Roofing
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[0] Other[[:I]
Brief Desc' tion f Proposqq�� +,, ` i 11
Work:_ L�'1 T1� I -t-�J�� K 30-+V\r00 �� � (�L)r1C�l�� �O�VVI
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa Nevi, io lse aMMI a extstin aar s ltcr= om of xfhe fo [a rng:
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 AUTHORIZAT.CON-TO;BE.COMPLETED-WHE14
'OWNERS AGENT aR CONTRACTOR APPLIES FOR BUIL:DINCr PERMIT
'-�°`v- " � �o- "1 C� r� as Owner of the subject
property 1
hereby authorize
to act on my behalf,in all matters relative work thonzed by this building permit application.
Signature of Owner Date
C%A-n �_ `)Q y(l`I:o Le— as-AwweWAuthorized
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 Nam
Si�tur,
04;wneaftent Date
•
Section 4. ZONING All Informatihh 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 '
Frontage
Setbacks Front
Side L:' ' R I L: R:
Rear
Building Height ;" — --
Bldg.Square Footage ( %
Open Space Footage % �— —
(Lot area minus bldg&paved E--
arkin
#of Parking Spaces
Fill: I
(volume*Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:' i
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#i
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES Q
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 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 NO Q
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 0 ,. NO 0
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
1
f Nortoampton
�r` E ng Department
�;
l� Main Street �. ►
i; oom 100 a>t
3 2004 N pton; AMA 01060a:
phone 41 587- 240 Fax 413-587-1272 an
,>
i
INSPEMIONS t s
AP11LICAT ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION? -SITE'INFORMATION
This sectron to 6e campteted by office
1.1 Property Address: n
71 � r
(� ZoFle, °Overlay Disfrrct_
C7IC)ba,
3 �{
ElmnS DiStF4Ll CB1Dis#nct
SECTION`2-PROPERTY OWNERSHIP/AUTHORIZED AGENT,
2.1 Owner of Record: ,
Name(Print) Current Mailing Address:
Telepbi ne'
ignature
2.2 Authorized Agent:
SCO i,I r ' S P i 04 P . t,arc
Namefrinti Current Mailing Address:
l
x-11?1)
ignature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
c m feted by ermit applicant
1. Building " (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing / 10 D L Building Permit Fee
4. Mechanical(HVAC) l P
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
d�
This Sectiort For Official°Use Only
Date ,
Building Perrnit'Number "Issued.
Signature: '
i
Building Commissioner/inspector of Buildings Date
File#BP-2005-0303
APPLICANT/CONTACT PERSON PRITCHARD DAVID W&
ADDRESS/PHONE 31 INDIAN HILL FLORENCE
PROPERTY LOCATION 31 INDIAN HILL
MAP 29 PARCEL 546 001 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 0/7 ZP
T_ypeof Construction: INSTALL BATHROOM IN LAUNDRY ROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y 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
INFf3R 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 Commission
,?- ��ld
Signature of Building O cial 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.
31 INDIAN HILL- BP-2005-0303
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-546 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2005-0303
Project# JS-2005-0219
Est.Cost: $8500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft): 15289.56 Owner: PRITCHARD DAVID W&
Zoning URA Applicant. PRITCHARD DAVID W &
AT: 31 INDIAN HILL
Applicant Address: Phone: Insurance:
31 INDIAN HILL
FLORENCEMA01062 ISSUED ON:9115104 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL BATHROOM IN LAUNDRY ROOM
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 Sienature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 9/15/04 0:00:00 519 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo