32C-202 (11) •SHAJyp�, cy�
Ll itg of Northampton r
�TlassRCl�[[SeLIS
DEPARTMENT OF BUILDING INSPECTIONS /?
INSPECTOR 212 Main Street • Municipal Building
North,unptan, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction sups:, so r. 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
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
�- tI fPp
R}� � 0y� (rii �f �>rz-tl�aiil}�to�1 —
o DEPARTMENT OP DUILDf)\G INSPECTIONS
j: 212 Alain Strcet A'funicipal Building
Northampton, Mass. 010GO
I, `fir O lUC E R'S C O NLP EN S ATZO N CN S URAN CE A I,IM A VIT
(li ccvs xJpermj(tcc)
«rIth a prulicipal place of business/reside'ncc at:
�{ v e` 'G A- l�n„t•Fi�n 1.a �'J� M�4 l 3°(n o o e;')
(SO-=/city/sta1 YZ3p)
do hereby certify, under the.pzins and penalties of pegury; h:l
( ) I am an employer providing the following wcrkcr's comocnsZz�oP cove 2gc for Inv
t1liptovees woriong on tills job:
(Lnn> == (Potic:Numbcr) (c:-pinion. tDate)
j I am a sole proortetor, general contractor or homeowner (ci c;e one) and have hired
the coairactors list d below who 1-12ve. the foUo%viDg worker's cocper.SP_iion aOLICies:
li ([+flI11C Oi 0:.....Ci0S) IRSL.rattC;. CGtnpiz /!GE1C t
(Nzmc of Conmcior) (Irl.sarzncc ComnazwPoUcc; \tumor) (%aDirzuon DaEe)
(Name of Coarraeto:) (Insuraace Compa=,;/Policy Numbr) (E�airaea Dale}
I .
((blame of Coacdctor) (I.aS11=c—_ Comr�y/Policy Numb r) (_xpi,,6ou Daft).
(atz.ch rd�3—:Oc1 to mcv� af«au�oa pe,• to.L7 coca r_oz)
{11�/I am a sole proprietor and have no one worl6ng for me.
( ) I am.a home owner performing all the work: myself.
NOTE:plesc be cwvt tit .1_)e hoa=w ner3�bo graphs pctiom to do � a oo a rc7aa Boric on c d"111=9 of
ao(mote th=Lbrvc-=ru to wb3ch the borzoo'.ocr rrsda oc oa the v-ow 6 zppurtca tbcco r_-c oo((~_te-.11v a>erdczod to be
�tploye-z unCe the�.uSdi c��-ti--.,.eo Act(GL157,3=t(5)�z4VG=b6=by a hom oa=fcr c lies_a permit cis n4'3—thC
1c 6r rta3u of en cgloyx under d6 W.Ck4ec Oompamitioa Aix_ -
I u.Z v.nd tba a Dopy of this mtcmcm ta.y bo C«xvrd ed tv tbo D•opnn.mm¢of 1u1+ al Acadc�7'C'M oC 4z ^fa tb.
Q
oovetth-c vc-jrcxiyoo aM Uui L•iltac to securc'eovera4sc under soaioa 2.5 A of MG 152 ew!ed to the to oa of airmail PIC�
ooc.i�of a tint or up to S I}00.00 ar0or ir�r- of up too=ycr rad aril pm.tio in t5c form of a Stop Work Order and a
Cub of S 100.00 z d-- zptia-A mr-
Fa���u+c Drily
pc,-m,t N(tmt---, ,
Lot
Situ of Liccn'C,JPcnnittcc --
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: 1 Not Applicable ❑
Name of License Holder: ►.t J�•ir� ��� L S (22 Q 191
_ License Number
�' �, `'6S� til alt 0�-
Address Expiration Date
Signature Telephone
9 ,Reg sfdirdcrHd669fm Not Applicable .❑
Com anv Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCEAFFIDAW (M.G.L°.c.152,_125C(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...... ❑
.. �
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 C7 Addition Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs (01 Decks (M Siding(01 Other[p)
Brief Descri tion of Proposed
Work: * ,
CYif�r
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
C1 °ern> oFlsseacev acdlatfi�,�x�slr>� -fia[csl mt � Alt
a. Use of building:One Family Two Family Other
b. Number of rooms in each family unit: T_ Number of Bathrooms
c. Is there a garage attached? t�L_>
d. Proposed Square footage of new construction. 3 b Dimensions Q; X 15, 0
e. Number of stories? 3
f. Method of heating?0 ., -",, _ Fireplaces or Woodstoves _Number of each
J g. Energy CA ervation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction `7✓�`C��L, /(�.rJ u�
i. Is construction within 100 ft,of wetlands? Yes V-1 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. S r✓e- VG •4 4 @
I. Septic Tank City Sewer ✓ Private well City water Supply ✓
SECTION 7a�--,OWN N-,TO BE COMPLETED-WHEN
OWNERS=AGENTOF�CON.'CTOIrZAI PLLIES E'OR Bf11LDING=PERMIT
..ul�w 1�L. ti(� rn.. Y t �. �-Z h S l.. as Owner of the subject
property ((�� l II
hereby authorize / 11LQ�,� s�`L� _
to pct on my behalf,in all matters relate a to work authorized by this building permit application.
Ct (( �(06
Si nature of Ow er V Date
I, L"I"t L) WCJ_(' . 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.
uj
Pri ame
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
3 Building Department
Lot Size
Frontage
Setbacks Front 1 Y t zY
Side L: R' �' L: R:t
Rear
Building Heightr
Bldg. Square Footage 1'ri vz % � a
Open Space Footage %
(Lot area minus bldg&paved .
parking)
#of Parking Spaces
Fill:
volume&Location ----
I i
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW YES
IF YES, date issued:#
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T�KNOW—0 YES
IF YES: enter Book ZS is/ Page! 1 69 and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q 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 0 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,excav 'on,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 s af� �, �_ .r
u In artment
LS U� L5 11 2 i Street
{ o 100 aM '
t a
S t MA 01060Se o
ph�ne 4 87 Fax 413-587-1272 ap
[APPLICATIIGN�Tf3'�(fQ. ,ALT R,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
''SECTION't-SITE INFORMATION
1.1 Propert Address: M Thisect[orxta6e�smp�efecbafEee
0
i I 1
1 Zotiew Quer[AVIDisfcr
4 ElitR �Q�SfCICt: r- 's' ., -'f IStCIL` .. ,
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED„AGENT
2.1 Owner of Record: to
f—(,- -Z--46t'-1 44.^k[C,,. c.Z:$K5IL-; ? �- Li
Am NI (P rint) Current Mailing Address:C � Telephone
ture
2.2 Authorized Agent:
,tnJlllcltJ J4 tMc.. 01301
Name(Print) Current Mailing Address:
( ct9Q� L t3-
Signature Telephone
SECTION 3-<ESTIMATED CONSTRUCTION:COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building:Permit Fee
2. Electrical (bp Estimated Total Cost of
3 v J o„ Construction from` 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
vow-
6. Total=(1 +2+3+4+5) b CU �.0 D Check Number
This.Secton For Official Use Only
Dafe _.
Building Permit Number-
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2007-0306
APPLICANT/CONTACT PERSON ANDREW T WALSH JR
ADDRESS/PHONE 9 FOREST AVE GREENFIELD (413) 522-7795 Q
PROPERTY LOCATION 85 WILLIAMS ST
MAP 32C PARCEL 202 001 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
Tvpeof Construction: ADD SCREEN PORCH&DEMO STAIRS _
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/Statement or License 082029
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IRMATION 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
ob
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,
85 WILLIAMS ST BP-2007-0306
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-202 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Deck Addition BUILDING PERMIT
Permit# BP-2007-0306
Protect# JS-2006-001674
Est. Cost: $16000.00
Fee: $68.00 PERMISSION IS HEREBY GRANTED TO:
Cont. Class: Contractor: License:
Use Group: ANDREW T WALSH JR 082029
I.of tizq,sa._it:Z: 3789.72 Owner: HAYMAKER ELIZABETH&
• T A: P•:
Zoning: URC Appiicant: i�1V is; .:` v 1 •v"� ' �I i,l%
AT: 85 WILLIAMS ST
Applicant Address: Phone: Insurance:
9 FOREST AVE (413) 522-7795
GREENFIELDMA01301 ISSUED ON.912812006 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD SCREEN PORCH & DEMO STAIRS
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: a 1 (0 ('3 of L6U 1 `)
Rough: Rough:/ob-ib f j House# Foundation:
Driveway Final:
Final: Final: / ) y
//// U j � J, � Rough Frame: 0;1
Gas: Fire Department Fireplace/Chimney:
Rough; '��0': Insulation:
Final: Smoke:. Final:0 K 1 f-/3 Flo
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL TION
Certificate of Occu anc -Signature:
FeeType: Date Paid: A motiut:
Building 9/28/2006 0:00:00 $68.001351
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Conunissioner-.Antl ony Patillo