32C-223 ¢'iKaMP�.
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a � jlUlassacliusetfs ,
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street 0 Municipal Building '
Northampton, MA 01060
,r
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:::'sor. 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 dwrier/res' is signature requesting exemption)
i will call to schedule ail rCyuii eu building iiiSYcGiivuS necessary wi ua., v.....,L.b Y
issued to me.
Date 6y 1d6 1 06
Address of work
location__ -79 CIA w l.(-
fy6 K; Ahnp-TdN , pAA o10.60
o�`� `1•I�� IIf ��Lll:fl}i11ll�JfDl1 -
DEPARTMENT OP DUILDf?,�C INSPECTIONS
212 Alain Strcct Municipal Building
Northampton, Mass_ 010G0
«'OR1Q.R'S CONOENSAT70N G�SU1ZA-NCE Al=, +VIT
1 � (IiccusccJpermJttcc)
%with a principal plat:. of businesshesidence zt:
(Sa=Vci ty/sui cfzi p)
do hereby certify, under tie pains 2nd penalties of penury; u`at
( } I an an employer providing the following %vorker's comocnsv don cove---Sc for Illy
employecs worUng on this job.
i -
(In_cur-:n=Comm) (Potico NtL�r) --- (1 :-pirtior, D2t`)
j -
O 12m a sole proprietor, general contractor or homeowner (c cie one) and Irve hued
the contracnors listed below wto Have the workers comoensa6on policies:
(L!aM-, 01 COn- t ZCIWS) (In i-,nncc Co1IlD1Il)-iPoJG -; ?�tt1II1LC:) (~?:JU°J 3^ Datc)
i
(Name of Contracr) 0=,L=cc C0MDan-a?0tIC-i NUMCer) (L»ir.6on Date)
l
(Name of Coturaclo,) (tnsurancc amp-ao)•/PaUq- Namb s) (Expiracioo Datc)
(N-—C Of C-uuactor) (Losutanc—c Comramy/Policy Numb:.r) (Expir6on Dale).
16dii0c51 c5cct.if nco---•to mr-!ud:iaformaloe pclaiaias to aL co=--a4n)
{ ) I am a sole proprietor and have no one worldrig for me.
I am-a home ovmer perforay.ng all the work myself.
NOTE:ple be agxm th. v }c bccaeoµacn wbo erapjay pCrt'a w to cio -;,ncc ors-e,v c tgair Fork cu of
ant tnoci th:a tar_tmf�is,c+tach the hotnoo^xncr r.d.or oc the l -mt z,� lh,-o Lz not carny occrd=cd to be
ctploycs uac--the w�i d7 o=p -,;on A=(GLI5Zs t(5)�s;*U 6=by.bomaoa-or fcr c tic--or pcxnit c=y c.id-o«tl:c
IcS21 0 =of ea crployo under dw Work e.CooapeoaaL Ad
I undcsZ.ad Ila.copy oCthu mto3>cw may bo foc-'.urd,d to,bu DcVur rd of i—i—d Accidcatj QQoo oClsa+--far lbo
covarx-E�c vcif cnioc a.'td tttu f iliac to c4curcbov=y4,�undcr ux7rioa 23A of MOL 132 cna led,.Iba of ;m;,,,l pcn+ -
comi=!Cta of a fiat orup to S 1 500.00 armor izocancy orup to Cu--yr3r=d 6%i1 pmx-l'Ja ill tx room oC.stop Work,Ord--.ad.
rim of S 100.00 a d--y tPiast tat
Foc dcp.rtxz�='t u,c only
PC;rtIU1 NLLIDI>G` +
ign,-t of Li crauucc
y
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction
�-Supervisor: Not Applicable ❑
Name of License Holder:
1 License Number
� --\1, - b
Add Expiration Date
Signature Telephone
Not Applicable -0
U "X �� 0
Company Name Re ist ation Number
Ad s Expiration Date
Telephone
SECTION 10-WORKER -SATION INSURANCE AFFIDAVIT(M.GL.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...... ❑
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 Deatuh)of u.e'14assachsetts General Taws.Annotated,von 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 Zonin Laws a tate of Massachusetts General Laws Annotated.
f� Homeowner Signature "
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [71 Siding[p] Other,[ P-Q. S
Brief Description of Proposed REPLACE 5'4%T f1..O oc CE O tjN , R4_�PLAG W o-I tJS PATS S'k Er--Tvd<_
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No (NSTAL L S A&0 S
Attached Narrative. Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa if New hoase and i a ciitiorr#o ezisting ti c comp'te 446, follow nc:
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
L Is construction within 1 DO 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 7at-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTORAPPLIESFOR"BUILDING PERMIT
1, 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
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
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
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bIdg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONTKNO� M YES 0
IF YES, date issued::'
IF YES: Was the permit recorded at the Registry of Deeds?
'
NO 0 DONT KNOW YES 0
IF YES: enter Book pu and/or Document#:
'
B. Does the site contain u brook, body of water urwetlands? NO _ DON70N�V YES
IF YES, has m permit been or need to be obtained from the Conservation Commission?
Needs tobmobtained �~� Obta�nad �~� Dmte |ssued.
'
^~� �~� '
C. Do any signs exist on the property? YES /—\ NO
IF YES, describe size, type and location:
D. Are there any proposed changes toor additions oy signs intended for the property? YES NO- ��
°
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,nr filling)over 1 acre orinit part cio common plan
that will disturb over 1 acne? YES F-� NO ��/
���
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
^
yr '
Depjrtmeot,.pse_,only:; .. ... w ..
City of Northampton i tatusofPermti ' '" W '"
Ifding Department u�lt,treuvaj�Perrnt � "
-� -� 212 Main Street SeweiSe�t►cAailabaidy" ` �
ILI'
halri }
Room 100 1Naerrlebrfity k
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N ampton, MA 01060 Jut,%'�
phone 41` -587-1240 Fax 413-587-1272 :
oll
AP I!SATIQN TQDq iNSTR!)GT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
"SECTION 1 -SITE INFORMATION
T[iis"secttatrto becomptetetl FyofFice
1.1 Property Address: r
r;
dA W L f� 5T Map 3:ot Unix
Zone rOveri N Dastnct
NUS+� 1A ff6 `J /A� D10�� '
c6 gistrIct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
/ /,�/ p Q�iti Ia6os �lw/L8
G e (9 V .' Telephone 9
Signature
2.2 Authorized Agent:
[yea (Print) Current Mailing Address:
si re Telephone
SECTION 3-ESTIMATTEE6NSTRUCTION'COSTS-
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 21000 Wa Building~Permit Fee �Q.� ryllN
2. Electrical G {ti)Estimated Total Cost of
I t 0U U Construction from 6
3. Plumbing Building Permit Fee �,✓-
4. Mechanical (HVAC) J tD• UCH
5. Fire Protection
6. Total=(1 +2+3+4+5) O d Check Number -7 2-:3 -r4. OG,_
This Section For Official Use Onl
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2006-1066
APPLICANT/CONTACT PERSON CDT CONSTRUCTION
ADDRESS/PHONE 158 NORTH MAPLE ST FLORENCE (413) 585-8677
PROPERTY LOCATION 79 HAWLEY ST
MAP 32C PARCEL 223 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
T peof Construction: REPLACE SHEETROCK CEILING WIRING PATCH SHEETROCK&REPAIRS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 003666
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 Commission
Signature of Bui ding 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.
79 HAWLEY ST BP-2006-1066
GIS#: COMMON WEALTH OF MASSACHUSETTS
Map:Block: 32C-223 CITY OF NORTHAMPTON
Lot: -001
Pemvt: BUlldlnq
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2006-1066
Project# JS-2006-1194
Est. Cost: $6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 4486.68 Owner: WANG FAMILY TRUST
Zoning: URC Applicant: WANG FAMILY TRUST
AT: 79 HAWLEY ST
Applicant Address: Phone: Insurance:
69 GRANTWOOD DR
AMHERSTMA01002 ISSUED ON:4,,'1012006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE SHEETROCK CEILING, WIRING,
PATCH SHEETROCK & REPAIRS
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: r 0 i
THIS PERMIT MAY BE REVOKED BY THE QTY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. '..,
: ✓ Signature:
Certificate of Occupancy
r�c, 1 -
FeeType: Date Paid: Amount:
Building 4/10/2006 0:00:00 $50.007231
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo