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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 780CNlR 108.3.4 to
act as his/her construction sup<:-:*Osor. The state defines"Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be a one or tW6 fami
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 b-uil ing department for the City o#'Northamptonwants arty persons)who-seek tv 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 fegulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfiIl),
sonotube holes (before pour) a rouzh 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
7
tand the above.
(H owner/residen s signature equesting zemption
I will call to schedule all required buildin inspections necessary for the building permit
- issued-to me
Date n
Address of work ,
location --
/ f 4-0 r
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E (riff Of {rIj:f11ailip foil _
R _ E .61 X5.AcfloccUa'
w o DEP/LRTMEI-47 OP BUILDr>,Ic INSPPCTIOI.'S _
I _
j 212 Main Strcct Municipal Building
j Northampton, Mass. 01060
_ WOR10EIZ'S CONI PENSA-nON MSUR-A-NCE AFFU),1A71-1"
—�--�s-Gt ; tree ------- - -- ---...-- -- -...._-_ -_.
Vrith z prncipal place of business/residence a . - --- -
h, �ctPt` U none=) c ��7e17�
/ (sic-t/cityl aLcla L � �'� /
+ do hereby certify, under thc.paui s and penalties of perjury, hai
( ) I am an employer providing the following's:orkces coin ocns��on cove age for m}
emplovecs woriong on this job:
(L2sur---n=Cont. r) (Polio:N'u-mbcr)
( ) I am a sole propriecor, general coa=cior or homeow-Der (c cie one) and have hired
the contractors listed below wbo 112ve the following worker s coMoen_-�a;ion pabcies:
-
j � _-
lNamc of CO:IMIC,0") (InRranc c- CoI p.-Url •pt�ouc �tL1II1:C:) ��:7iidOQO l�1tC)
(Namc of Coairetor) (Inssranc°. ComoaawPol.im Nunc_r) Daie)
CName of CGUMM to
j ) (In.stua>;ce Comra.o}'/Po[;c}- Z`i:>,sh:.r) (Expiraea Daic)
I
I
(Name of Coaaacior) Gmsucan=ComcaayRolicy Numb:r) (Expirtion Dar-).
(aII.a�adu�ocyl�cC.ifecea.+--y u a,d�v iaforau;oa pey.iaia�to.17 mere)
( ) I am a sole pFOprietor and have no one working for me.
I am,a home o,,vner performing all the work myself.
NOTE:prose be an arc L*u c hcmca+vcn wt�o cspioy pc•.aoa co -. c=--=oa cr rcpza work on.d%—U--a of
one ae«thra tsu J in«'sets the bocnoownc reud�«oa the Qou •.,tb'e cox�c-i1y oecr'd ai to be
cPlayc-s unZ=the�. ;==P=r-,:oa A�(GUI 52-=1(5)��pC=600 by a bomco -Da fm c G�_or pc-mit c=y c nd==cSc
Icy^zi n.n."of ea ez�loyx aad r die Wocicdc Coc�aom.yioo Ae�
I t?ad<-ss+.nd tha a Dopy oC lhi�coat®mi m.y b�for-w•ard.d to cSe pcpnr�mco¢of Ivdazric!AccLczz�'Offioo of lr�u�ooe for tb.
covca��ciCctioa nad IiLt C--il�to so�uc tovcra��•,�sxcion 25 A of}.t4L i S2 m Ic=d to the iazpastioa of cimiaa!perzkio
eoa---tz of a Erne orup to s I Soo-oo.rdicx of up to oo yr_r end ci a pmaYia io tsc form ora stop work Ord--and a
rim of S 100.00 i e;y cPi=
F,Mc uac Doty
Permit T NumL---7
tot„ 3
turc of Liter crmitic c
SECTION 8-CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holdee
License Number
Address Expiration Date
Signature Telephone
� Re'iaeEFamem " �rerrteriGvtoa+rto _ - � a; Not Applicable ❑
Company Name Registration-Num er - --
Address w Expiration Date
Telephone
SECTION 10 WORKERS'COMPENSATION`INSURANCE.AFFIDAvrlr(M:G.L,c.152,§250(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 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"homeo er"certifi es and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,S to nd cot Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature ✓/`'
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check allapplicable)
New House ❑ Addition ❑.., Replacement Windows Alteration(s) ❑ Roofing
Or Doors ED
Accessory Bldg. ❑ Demolition New Signs [0] Decks Siding[0] Other[0]
Brief Description of Proposed /
W-.ork: lifd (`�
- -
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Y s No
Plans Attached Roll -Sheet
6a [€N �v muse id or c ct �a t xtstl c aaslnct cornp�etemt fo!aurr'ic>W
^f b:'Idi^• O^�CMrrd�`i Twn 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? replaces or Woodstoves Number of each
j
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 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
SECTION Ta-OWNERAUTHORIZATION TOeBE COMPLETED WHEN,
OWNERS AGENT"OR CONTRACT OR A(PLIES FOR BOLDING:PERMIT
as Owner of the subject
prope
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
P 1. / �� a Own Authorized
Agent he y declare that the state ents and information on the foregoing application are true and accurate,to the of my knowledge
and belief.
Signed under the pains and penalties of perjury.
L�P�ri'n\Na
0
t a 9f Owner gent at
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
Side L: ° L: R:'
Rear
Building Height
t
Bldg.Square Footage i %
Open Space Footage _ %
(Lot area minus bldg&paved i
-kin
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Perm it/Variance/Fi nqing ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the 9eqistry of Deeds?
NO 0 DONT KNOW M YES Q
IF YES: enter Book Page; ` and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q 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 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 Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excPvation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q , NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Nort'Pampton
Building 6 g
212 Main Street `
Room 100
Northampton; AMA 01060 T
phone 413-587-1240 Fax 413-587-1272 PIo Slfetns
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
_71 SECTION -SITE=INFORMATION
This section to be completed byt cffce
1.1 Proper! dress: }
�y A/� /
Zane O�r erlav�IStrict
�► �v���r✓mil � ®�a� '
trtct iz
x
ElnrSf D�s CB Disfrict
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner Qf Record: ,
-Name(P' )- urrent Mailing Ad ss:a
_
Telepho-n'e 7�
Signature
2.2 Authori ed A ent:
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 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
11 Construction from 6'
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection Ali
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date.
Building Permit Number. Issued:
Signature: !'
i
Building Commissionertinspector of Buildings Date
File#BP-2006-0981
APPLICANT/CONTACT PERSON FLYNN CHRISTOPHER T&AISJAH T
ADDRESS/PHONE 24 PHILLIPS PL NORTHAMPTON Q 584-7474 O
PROPERTY LOCATION 76 HAWLEY ST
MAP 32C PARCEL 227 001 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
Typeof Construction: REMOVE PLASTER,SHEETROCK&INSUL 3RD FLR
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
INF_O,PAIATION 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 ssion
*� Z 71�6�
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.
76 HA`1VLEY ST BP-2006-0981
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-227 CITY OF NORTHAMPTON
Lot: -001
Permit: BUIIdIng
CateQory: BUILDING PERMIT
.Permit# BP-2006-0981
Project# _ JS-2006-1459
Est. Cost: $2000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
disc Group: Homeowner as Contractor
Lot Si;-(.-(s ft.j: 4486.68 Owner: FLYNN CHRISTOPHER T&AISJAH T
ZoninuT: URC Applicant: FLYNN CHRISTOPHER T & AISJAH T
AT. 76 HAWI-EY ST
Applicant Address: -'hone: Insurance:
24 PHILLIPS PL _�) 584-7474 (�
NORTHAMPTONMA01060 LSSUED ON:3,%8 12006 0.00:00
TO PERFORItiI THE FOLLOWING WORK.-REMOVE PLASTER, SHEETROCK & INSUL 3RD
FLR
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Undi rgrou►►d: Service: Meter:
Footings:
Rough: Rough:'.— T 2 , House 4 Foundation:
Driveway Final:
Final: Final:
q t�ti t,EC Rough Frame:
o PE
as: Fire Department Fireplace/Chimney-
Rough: Oil: Insulation:
Final: Smoke: Final: OK (2, LL(O� (,otA4 S
THIS PETlART A AY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATIWi OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc� Signature: _
FeeT e: Date Paid: Amount:
Building 3/28/2006 0:00:00 $50.003238
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo