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INSPECTOR 212 Main Street • Municipal B uilding
Nortb=ptm, MA 01060
HOME OWNER EXEMPTION ACIi'NOWLEDrEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act a. Lis/her construction sups_-,' SOr. The state defines "Homeowner" as, "i erson(s)
who owns a parcel on which he/she resides or intends to be, a one or two family
welling, 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 who
The building-department for the City of Northampton wants any per sons)who seek to
use the home owner exemption, to act as thew`own const action Super isC, 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 back-fill).
sonotube holes (before pour). a rough building inspection (before work is
_cane led),in-sulatio-n-ins€),ection (if required)andaT'1naLhuffdina 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 occupancv
until-the work--an-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 DEI AY 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
The Comrnonwealih of1Y_fassachusetts
— Department oflndustxza1 Accidents
0-
.�-- Njiiceoflnyesezgarions
tai 600 Washin�oton Street
Boston,3L4 02111
www.massa ov/din
Workers" Compensation Insurance A-iidaz-it: Builders/Contractors/Electricians/PIumbers
Applicant Information Please Print L�,el�bIv
Name(Business/cr-,mizadonadividual): (}1!0/�Gt> p• s�16�1�p�j Tr. � ' 11- (4{r924-ry
T
Address: 0 i(1 W Oi k d .
r l
City/State/Zip: S-DP�C' Tl c1,N�A ��3�3 Phone.:
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a gene-al contractor and I
1.❑ I am a employer with - 6. E]-New construction
_ employees (fail and/or part-time).* have hired the sub-contractors
2Z I am a sole proprietor or partner- �d on the attached sheet 7- �Remodeling
I ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. employees and have workers'
fN suua
o workers'comp_inuce COMM.insurance.}
9. F7 Buildinz addition
required_] 5- ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers'comp. ridut of exemption per MGL 12.0 Roof repairs
insurance requited.]t c. 152,§1(4), and we have no
employees. [No workers' 13-❑ Other
comp.insurance required.]
any ican caer:a oox�_ must a so out tae secnan oe:ow snowma ther worik== cotapessanon policy information.
Homeowners who subrnit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such-
:Contractors that check this box must.attached an additional sheer showing the name of the sub-contractors and state whether or not those=tides have
emplove— If the sub-conaaetors have employees,they must provide their workers'comp.policy nurnoer.
I am an employer that is providin,;workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can Iead to the imposition of criminal penalties of a
fine up to S 1 500-00 and/or one-year imprisonment,as well as civil penalties in the fora of a STOP WORK ORDER and a fine
of up to$250-00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for instance coverage verification.
I do hereby ce under the pa' d p hies of perjury that the information provided above is true and correct
---
a VVU �— --— r 10111 V-7
Late:
Phone—
LOt e only. 1lo not wrrte en this area, to be completed by city or town of
wn: _ -__ --___ - -----____-- _---- —P-e rn t/License
thority(circle one):
f Health 2.Building Department ?. City/Town Clerk 4.Electrical Inspector S.PIumbing Inspector
rson: Phone_:
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: a/ Not Applicable ❑
Name of License Holder: 1 t(Mot 5 p- ��G•V b(� , 1 054093
152. c4nw �YCY ' ► Q�3 /� License Number
Address Expiration`Date
Signature Telephone
9.Registered Home Improvement Contractor: Not Applicable ❑
b73 9
Company Name Registration Number
T9_ CotrPeA+yY 5]o- /01
Address 157— ClO r W Expiration Date
•QeCT TJC 11 0 MA - 0I33 7 Telephone411,325-52 I
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...... ❑
11. - Horne Owner Exemption
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors 1771
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[lam] Other[Q]
Brief Descripti n of Pro ose
Work: Y et l v/ r i �I iJ V1 l V\ 4411111 as ���
Alteration of existing bedroom Yes No Adding new bedroom Yes _No � +AC��
Attached Narrative nov ing unfirfished base ent Ye No
Plans Attached Roll -Sheet � j1-7 Q-7 p�� ArcV i a� S L
6a. If New house and or addition to existing housing, complete the following: h►IA
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-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,
` �- ' as Owner of the subject
property
hereby authorize " J v %Pk T-2-
-2-
to act on my behalf, in all petters relative to ork authorized by this building permit application.
Signature of Owner Date
I,
as Owner/Authorized
Aqent 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 I
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
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 0 DONT KNOW � 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 �A) YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained l Obtained 0 Date Issued:
C. Do any signs exist on the property? YES NO
Ir 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:
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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
Building Department Curb Cut/Driveway Permit
212 Main Street Sewer/Septic Availability
Room 100 Water/Wel],Availability '
Northampton, MA 01060 Two Sets of Structural Plans
phone 413-587-1240 Fax 413-587-1272 PIoUSite Plans
Other Specify
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This terion to be completed by office
1.1 Property Address:
13 K'j 1A e,1 GZ �uG _ �..' OCT M1p2 2001 �. > Lot Unit
I
No f+ _a mr •p v\/ A J1 1 �. __ Overlay District
t`t V1 '`�` DE� NQl dG!
CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
toaa OY+} CIVIAh4DV � A
Name(Print)J Current Mailing Address.
Telephone
Signature yh�
2.2 Authorized Agent: 16-L ea n A 1z A -
41 S c�t� �� 9.p64Y iGl a - a 13-7 3
Tt� a� h , �
Name(Pr t) ,�\� Current Mailing Address:
I A �l9' j13 . 32S _ 5:;_q q
Signature V Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 0001 r (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
.i
6. Total= (1 +2+3+4+5)
r Check Number
This Section For Official Use Only
Date
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Bui ing–"rd s— Date
File#BP-2008-0396
APPLICANT/CONTACT PERSON THOMAS P SHARPE JR
ADDRESS/PHONE 152 CONWAY RD SOUTH DEERFIELD (413) 665-3047
PROPERTY LOCATION 13 KINGSLEY AVE
MAP 32C PARCEL 158 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid J
Typeof Construction: SISTER NEW FRAMING MATERIAL TO EXISTING ATTIC
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 054083
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 Co sion Permit DPW Storm Water Management
Signature of Building Official Da e
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.
13 KINGSLEY AVE BP-2008-0489
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 158 CITY OF NORTHAMPTON
Lot: -001_ PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catea,ory:Non structural interior renovations BUILDING PERMIT
I'e;n,it BP-2008-0489
Project# JS-2008-000166
Est. Cost: $13400.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin THOMAS P SHARPE JR 054083
Lot Size(sg. fr.?: 3920.40 Owner: SALLOOM ROGER W
Antjlic-ant: THOM-A.S P.S.HARPE J_R
AT. 13 KINGSLEY AVE
Applicant Address: Phone: Insurance:
152 CONWAY RD (413) 665-3047
SOUTH DEERFIELDMA013731SSUED ON:1111312007 0:00:00
TO PERFORM THE FOLLOWING WORK:INSULATE & SHEETROCK RIGHT SIDE UNIT
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: j�g C %
Rough Frame:
Fire De artmentJ ✓i Fireplace/Chimney:
I�ouah: Oil: " Insulation:
7��'.. �: �d ' / Final: 0 V� fJ /J -0 it
Final: Smoke:Z ,,�' ��
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIO „ . h
Certificate of Occupanc r
signatue:
FeeT y e: Date Paid: Amount:
Building 11/13/2007 0:00:00 $65.001977
212 Main Street, Phone(413)587-1240,Fa::: (413)587-1272
Building Commissioucr-Anthony Patiilo