32C-204 (4) goo "e Gl itp oaf Xart4auipta rt L =
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m DEPARTMENT OF BUILDING INSPECTIONS /?
INSPECTOR 212 Main Street • Municipal Building '
Northampton, MA 01060
se
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supc.-.,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
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
$ 6 fi?asersrflnsrtls '
t DEPfitTMENT Of' LUILDMG INSPECTIONS
212 Main Street ' Municipal Buil(ling j-
Nlorthampton, Mass. 01060
WORKER'S COMTE.NSATZON INSURANCE /�FFIDAVlT
v"itll a principal place, of busiresrlre:;iecnc
SLTC-,Ucit% -,21 Y: n)
do Hereby Ccr-dfti7 unr r dic p;:irls nd pena itic`.; of
I am an cmployCi- providing the folio'.-;M,L ••'."i)1-kcr's C0117pCI1snon GCwCIT: C 0' II7}'
(nzlployees Nvo6dng on this job:
(Lasm ct ampain') e c, Ntt rlrr) ----- ("r�. .iruon Date)
( j I a-m a sole proprietor, centracror c,r homeo"'ner (circle one) and ',av;, hired
the contractors listed beio`a;;'hC ;: the `011 .;: `ro;ke s com-L)n ion
CNI me of ConLractor) (IAS,ui•:'.nC l vI :ir, Gl1C{ Nll3I1t i) T. 0' Date)
(Name of Connz mor) _ (7aZSUr,_nc Co r_.,�iPedic]' Ni r� r) (l: tioa Date)
(Name of Contractor) (1S1S1 3S1Cti ComF �.;ir'o1i Nlun �r) -,_x; rd._ Laic)
- (Name of Contractor) -- (Insura is-- io-: Date}
l
C 1 tl Tl tI sole I?fUl)I]CtUi 2'.111 lar?VC no oIle for iIl -
�
NO"rIi:Phase be nwajc Ls:a i]c Ir.<r�o„ar_rs—,.3 ;r- n::>.<< �r�nc�ar::_n m cr:-;:air ... _..
not ux,ce than airm units in tx x;L .t.-.:s<r.t cr s'Lhc c c cr_t( -Y-f2jIy cc••:
c.1ployc3 un cis t}r_ivcri; s ca:z:- >_i-c A.,-* S2�s!(51;.',, ._a:icn by a hotnoo -cr`cr
legal etatua of an amp toyer uod'er tLn W kcxe t coo—TOr_-.ik o/'.cL .
I u xL,-r t,nd th.1 x cm,y of tai,cistc.'s1 mvy bo fot'wd-3 to tl»IYt uu rn of 1.dz11lrinl OH-ic of is .r =a for lax
covernc verif=ioc and that f:.iltuc to:- t eoti-ct uz 3::e,nM 25A of MOM 152 can lui to the im ziti-of r i.�]Pn=-1:a
w=asting of a f-ir>,of up to 51.500.00 n:`--`or i-' riv t :'1 of::r to cr.:)-,w e-.]civil,,,ilia in do fc-,nn of n S!r.,';,'c;i-Ord tr 1 e
Lren of s I OO.00 a day
F,dq uunatal u.c uil y
4/ Ycrrn;t 1�Itunfx:.r --------------------
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SCTONB GONSRUCTION':SERVIGES
8.1 Licensed Construction Supmiso r: Not Applicable ❑
Name of License Holder :
• � �1 �� �. � License Numb6r
Add r s � ���/ � EWirafidfi Date
Sign ture Telephone
i
v 1.
e ere . orn m r '. e 'en .Con ractor.' Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTI0H�,JD W0 2KERS' COMPENSATION INSURANCE-AFFIDAVIT{M:G:L..c. -52, § 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...... ❑
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 acecptable 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 ZoninoLaws and State of Massachusetts General Laws Annotated.
Homeowner Signature
i
i
SfGT05 Sf2IONO.FROPOSED�VYORK»check all a �I�cale � y
, F.
��
5?ate •':".,'a.
New House ❑ Addition ❑ Replacement Windows [Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ } Siding[ ] Other[ ]
Brief Description of Proposed Work: w
Alteration of existing bedroom Yes No Adding new room Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0• Sheet 0
V 07Mdit fon to xi sting#a.ous ng, .comp e e :e fol7;MM:
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 .
I. Septic Tank City Sewer Private well City water Supply
ECT1i� , DIVINE i�UTORIZATION TO BE COMPLETED WHEN
IYftS �iE�t F CONRACTOR APPLIES FOR 8U1LD1NG PERMIT
as Owner of the subject property
hereby authorize /L C to act on
my behalf, in all matters rela iv to work authorize by this building permit application.
Signature of Owner Date
I 6nZ19
as OwneriAuthorlzed Agent
hereby declare that t statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and p !ties of perju
Print Name
S g ature of Owner/Agent Date 6 C/
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 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 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. Are there any proposed changes to or additions of signs intended for the property?YES —
No
IF-YES, describe size, type and location:
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413.587.1240 Fax 413-587.1272 t
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
r
1.1 Property Address: •�J /`��G��J�, `,',I �� � ,R �
Maps L rain
Zon
R<
Elm 'District:: C8 , stet
SECTION 2- PROPERTY OWNERSHIP/AUTHQRIZED`A GENT
. f
n nl � r> rr.r•,,
2.1 Owner of Record:
Name(Print) Current Mailing Address:
r
�( Telephone
Sigr`ature
2,2 Authorized Agent:
!
Nam Print) /) Current Mailing Address: `
� - 0�7z��
Sig ature elephone
SE TION:,1 ESTIMATED CONcST.RUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use?Only
completed by ermit applicant
1. Building (a) Building Perrnit Fee
2. Electrical (b) 7_:timated Total'Costof
_ Construction.from 6'
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) I
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check dumber
This Section For Official Use Only,
Building Permit Number: Date issued:
Signature: - _ '
Date
Building CommissionerAnrSpector of Buildings
-T
7 KARY ST BP-2004-0754
CIS#: COMMONWEALTH OF MASSACHUSETTS
MU:Block: 32C-204 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0754
Project# JS-2004-1103
Est.Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: James Roberts 117154
Lot Size(sq. ft.): 3005.64 Owner: HICKS BERNADETTE
Zoning URC Applicant: James Roberts
AT. 7 KARY ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON.1122104 0:00:00
TO PERFORM THE FOLLOWING WORK.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:
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• Receipt No: Date Paid: Check No: Amount:
Building 1/22/04 0:00:00 2012 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo