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O��ttiAM p�O e
DEPARTMENT OF BUILDING INSPECTIONS /?
INSPECTOR 212 Main Street • Municipal Building '
Nortli-unpton, MA 01060 s
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as has/her construction sups: ,- sor. T he 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,// � / � 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 � •
(..>-i 13 f �arfljal�t}�fott
j _61 43 awcllascIfa* _
DEPARTME1,T OP DUILDr)\,G INSPecTiONS
212 Alain Strcct befunicipal Building
i
Northampton, Mass. 01060
i
�N'01 IZ'S CO6'fP)✓NSA n(DN L'A'SURACF AFFL)Avl'z'
_ 1
I
(li er:n_s=/permi tf=)
v."th a principal place of business/residencc at:
(Sur--Uci ty/sZatefD p)
do hereby certify, under the.pp-Mi and penalties of perJury; har
( } I un an employer providing the following %vorkcr`s compens��o, covemSe for 111y
i
employces wortang on tills job:
- (Las rte=Comrsv) (PcLic: Nu r) --- (r;pir�aon Dam} '
O I am a sole proprietor, geoeral contractor or homeowner (ci:cie one) aDd have hired
the cone-a(nors listed below who have the foUo ' g workers comnen_adon policies:
i
('11am: of CO_^.'^ct0r) Onsuranc;c Cornoin)•«'obc; Datc)
i
(Name of Conmaor) uanc Compan)rPo!ie; \trncr'r) �a�ir Lion Date)
(Name of Connaao;) (LaSUrancc CompanyPouq- Numtu) (Espirtion Datc)
(Name of Contractor) (Insurmcc Comcaay/PoUcy Numbs) (E�pi z600 Datt).
(LIISC�_ddi�oczl bcc,if ncoe _ry to c�c?ud;iaformaa oa pertaiaias to.1.I eoa7-rc:-�) ,
( ) I am a sole proprietor and bave no one working for me.
am,z home owner perforr=g all the work myself.
NOTE:plesc be ew ue o 4 rc 6om-owvcra wbo aaplay pcsom to Y C=--, Sao c rcp x-uric on of
no(mote t;, a throe Lmru is which the bo�rcidc or oa the p-ounca+ zppurtea:zs tbcrn L-c w(C=)=Vy oo=.d=-rd to be
cirployca uY c the.«i c1s oc�oo Aa(GLL 5Za 1(5)�appU=600 by a bommaacr for.ba .or permi r>_y cvid_occ tl:c
Ic-ss1 n-n.,of aA c=pIey.c under dru W.,kf e,C�i AeL
d>ha��.or th:.��m.y�•ror�.nrdde a tha DopLrsmcai or tn�atncl ncedcS�o��or tn�cr.�oe ror tb.
eoveL.sc"etCeslioo aad th1 L-il(�e to soayrc toverit�e tmdrt s.xiion 25A of MGL 152 can IcLd to the impoxIIioo of aimiWJ peastlia
oomisarg
-17-Gnc orup to 51_�OO.00 ardor orup to ooc ysur end ci j pmetio w t5c form or a Stop work Ord--Lad.
fl=of 5100.00 I dey cpiast t>x
', for.'.yr-^^�••t u,c only .
Pcrmit Numtx'1 -
�� Lot
SIPZturc of Lic=,_,c,l crmn uc,= ) d
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable Ik
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable _1101
9�B Qistere"'�'1=10rilE`r�L11PCQ17ement'�i'OntCaGtOr'�' °��� c�z �_,��:G,��r. rws�>,'�.�'., �ri.3�`s;��4
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 1'0-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...... ❑
AWNWA
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 onin Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature '"•
SECTIONS-.DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [� Addition ❑ Replacement Windows Alteration(s) ❑ Roofing F-1
Or Doors ❑
Accessory Bldg. Demolition ❑ New Signs [o] Decks [❑ Siding[Cl] Other[p]
Brief Description of Proposed
Work: T
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
t 4=r '�. .. c�
ek-'1f 4Whonse afar„ar dlt►or fto.e�clst ng.hnus�nc ccr3rna e e of dwrnq
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 900 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 Ta-'OWNER.AUTHORIZATION--TO�B,E`COMP.LETED ;WHEN
OWNERS AGENT OR CONTRACTOR-APPLIES FOR$UIL`DING PERMIT
i 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
41 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
ate
Signature of Owner/Agent
r t
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
�J/� / This column to be filled in by
A A t �i Building Department
Lot Size _ #17F Yp
Frontage
Setbacks Front f
Side L:1__1 R: L:6 R: ?
Rear `
Building Height
Bldg. Square Footage %
Open Space Footage % 1
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill: v
(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:'
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 DONT KNOW 0 YES 0
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. 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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Gilding Department
212 Main Street
w Room 100
No ampton, MA 01060
p one 41 - 87-1240 Fax 413-587-1272
NP,
APPLICATION TOI,QQNSTRU ,T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE'INFORMATION
Tftas sectron be completed by office
1.1 Property Address:
�A M ri Fr of t unit
Kl
Zone Oye�iay Otst�rctt
"MGImSt."DistG[ct' ;; ;"- t CB�Distnct '` .
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZEQ AGENT
2.1 Owner of Record:
Name(Print) ` Current Mailing Address:
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
completed by ermit applicant
1. Building r (a),Btxilding--Perm. it Fee
2. Electrical >>(b)Estimated-,Total Cost-of
�i 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 Commissioner/Inspector of Buildings Date
File#BP-2006-1382
APPLICANT/CONTACT PERSON WILLARD MICHAEL F SR
ADDRESS/PHONE 99 WILLIAMS ST NORTHAMPTON Q 584-7574 Q
PROPERTY LOCATION 99 WILLIAMS ST
MAP 32C PARCEL 199 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 11 0 r—
Fee Paid Or TL70 W7 0%,J
Typeof Construction: RELOCATE 10 X 20 SHED&INSTALL ABOVE GROUND POOL
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
INFO ATION PRESENTED:
pproved 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 ssion
1
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.
BP-2006-1382
CIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2006-1382
Project# JS-2006-2051
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 19384.20 Owner: WILLARD MICHAEL F SR
Zoning.URC Applicant: WILLARD MICHAEL F SR
AT. 99 WILLIAMS ST
Applicant Address: Phone: Insurance:
99 WILLIAMS ST O 584-7574 O
NORTHAM PTONMA01 060 ISSUED ON:612312006 0:00:00
TO PERFORM THE FOLLOWING WORK.-RELOCATE 10 X 20 SHED & INSTALL 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 6/23/2006 0:00:00 $25.002428
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo