32C-193 O4�1iAMp1O
�idssA[hliSttt6 -
of Wort4aniptfin
�-, DEPARTMENT OF BUILDING 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 has/her construction sups-:isor. 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
understand the above.
(Home owner res' ent'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
4,IttI.H,I,T �\
g Gl Iit�T Of �l'L7a tfi�illl}Itnll
�` 6 ��rssnchnsrtls'
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DEPARTMENT' Of' LUILDDJ G INSPECT-IONS
212 Main Street ' Municipal Builtling
Northampton, Mass. 01060
WOMCER'S COMTENSA'T.TON INSURANCE A + AVI.T
i
,lth a principal place of busiressJrc-s'dcncI- a,:
----- ------ — --- ---- -------- -- - tpllone
(sire:tici t•;i::,ai�:�-,-�p)
do licreby cer-df'; lII1C' ;l- t11C gams anc pe-n hies of pc:r'Ilry, -hilt.
( ) I
am an employer provldlnj the iollov"MC '•':QI'r:CrS coIl'1pensat-ior cOVCrr:`C for Iry
employets wor�driPg on LTis job:
(L=ranca Company) olio;NLL-nbcr) -- (Fxpirzi on Data)
( ) I am a sole proprietor, general non]eo;'aDu (cLrcle 012e) and ''have ilireci
the contractors listed beiow-,ho ha „ the `olla,�
^r. ; or s coL p
(1:QLI]C Of COn1I 1ciGr) (Trisumnc Nwnbci) Date)
}
(Name of Contr:cior) -- (Imsu ncc Co-�D_,1vfpc'hc-" Nlumtr--r) -ticrl Date
(Name of Contmcior) (lns'uratic: t_om /t -xr:;nor, Dalc)
(Name of Contractor) -- (Iilst rand Comrr:Iy!Policy Nu.mb�r) (F: i-aio Date)
(rlLid,:d'!,�oe:a1 t?::et:..._-.... :n:.._.�._.. crcu::a:r-_._.::rr,'.,ell r:<:.ro dc::•)
1. I i1IT1 it sole proprie,ol, L-id iliLV no oI c '.'.'i;rhiii`{ for 711-1.
I :?in i? l]onle t;\V?1C" 'l)Ci:Cr1?]IP.r' al i_. iii_ self.
r
NU TT.:pleat be nti+y t L;s:.tuilc txcco„ir:„',-� i:�ncc a:;_n G m Cr:.,air
not tiibce th.n throo uni+j in%%J-,-di he f ,rrr res:e:=or a; ,"t
tmploye3 un&-r lhr Svc is s cC x—:_ti^e.:-.r:((-,T ��s!(51;,'F:,•:ca ie;,by n ho:tro„-.�.`cr e L•cc_,e cc F=r.;:i::- '.mcc t..
Ie821 rtalur of an oaxployx under tL•o Wo,kce. o i erra Lion!.eL
I undc--tiaad tbi f a copy of tJv riatc s_•c:xy bo fcK •W led to t!»U-Ii L—rv.of Inda>ztriel Midm!Y C!ri oo of is 1:rc s o for tfx
covaz£c vei Ifir_tiw and tIL t fiulurc to t- :cmvcr_g!�un3c4'sc,:.iM 25A of MGL.152 can Ic_d to the imposition of r`air_]pcnalia
oomisting of a firr-of up to S 1.SOO.00 an1'cr i^:nrivr.�x:`1 of;,p to cn-}--r a^.j civil penalt es in do frnn of n S!c,`::c Y Ch erd
f r-1 of S t OOAO•d-ty a pairml rn..
roc dq uun:fsl u.e Drily i
PcrrnitNumlx:r ____.------------
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Signature of I.ics I crnt iitr::. `r
SCON=8Cta1Sf2UCT IQN:SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
x _ .: men., n'Ira Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECT O e ,'WOfERS',�=COMP,ENSA?:ION 1tJSURANCE AFFIDAVIT(M G L. e 152, § 2506))
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...... ❑
f
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"homeo«mer" 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 buildinE 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
Zallo mpt on Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
wner Signature —
I
n
U O R�OPOSED`WORK ch c a 11
t d Nj
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ DemolitionC2r" New Sigps q Decks [ ] S' ing[ ) _ Other [ ]
Brief Description of Proposed Work: r av
Alteration of existing bedroom Yes_uNo Adding new bedroom Yes _�No
Attached Narrative 0 Renovating unfinished basement Yes (/No
Plans Attached Roll 0- Sheet 0
itfon to fsin� ngknp re eel =ng
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 .
1. Septic Tank City Sewer Private well City water Supply
IZATON 70 BE COIVIPLEI�ED WHE[�
0 . S ACTOR APPLIES FOR B11LD�1NG PI_RIYIIT
I, as Owner of the subject property
hereby authorize to ac;. or
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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
Signattire of Owner/Ag t D
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 X _ 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 k' 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. Ar there any proposed changes to or additions of signs intended for the property?YES`
No
IF-YES, describe size, type and location:
-fit of Northampton
`Vj �� d ng Department
: �
Main Street
{ Room 100
c� ^C' loltnlpton, MA 01060
phone 413.87-1240 Fax 413.587.1272
...... APP-L1CAT•1OWTO-CONSTOCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
$E C TION;a - SITE INFORM"A ON
1.1 Property Address: µ Tf s see o fific
[
a
/Vd✓'?'f7r9m�� To r'1 �iq �n r ��
SE TfiON.2 - PROPERTY OWNERSHIP/AUTHO ]ZED AGENT
2.1 Owner of Record:
Name(Print) Current ail Address-
Telephone
Signature _Y�
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
NQ'
ESTIMATE<D CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Usdsoftly
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Elec.rical (b) .stimated 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
Building..ermit.N umber: _ Date issued:
ggnature:
Building Corr missior er/inspector of Buildings,, Date
File#BP-2004-0034
APPLICANT/CONTACT PERSON CAPUTO VICTOR F JR&DENISE M
ADDRESS/PHONE 4 HYDE HILL BRANCH RD o249--3J'7
PROPERTY LOCATION 22 HOCKANUM RD
MAP 32C PARCEL 193 001 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
s
Typeof Construction: REBUILD 6 R 6 PORCH&STRIP&SHINGLE ROOF
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 ssion
Z
Signature of Building Of icial 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.
22 HOCKANUM RD BP-2004-0034
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 193 CITY OF NORTHAMPTON
Lot: -001
Permit: Bui ing
Category: BUILDING PERMIT
Permit# BP-2004-0034
Project# JS-2004-0056
Est. Cost:$5000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 7710.12 Owner. CAPUTO VICTOR F JR&DENISE M
7opine:URr_ A olicant. CAPUTO VICTOR F JR & DENISE M
AT: 22 HOCKANUoi RD
Applicant Address: Phone: Insurance:
4 HYDE HILL BRANCH RD (413)268-3177 0
WILLIAMSBURGMA01096 ISSUED ON:719103 0.00:00
TO PERFORM THE FOLLOWING WORK.-REBUILD 6 X 6 PORCH & STRIP & SHINGLE ROOF
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: `�d L
Driveway Final: 7`��"��
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.
f
Certificate of Occupancy Si nature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 7/9/03 0:00:00 1833 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Conunissioner-Anthony Patillo