32C-233 (5) ,.Crztlr of Wart4anzptan L =
1�8'J4AClf lLStftB -
w DEPARTMENT OF BUILDD�,'G INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building
Northampton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act aS i:is/her construction sup,;: .,*,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 famity- -
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 r'.egulations. 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, ?7)"( Cb J fl L 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 l I -¢ _
Address of work
location It e9pI .001k S F CkGul't.JAi 'r�J
,�-ttv�rnT ,r•. -
/ —
of 'Nol:flji3111p!oil
r1 i311t([[nLltl a' —
o DEPARTMEI T OF BUILDING INSPECT[OI"s
212 Main Strcct ' 'Nfuaicipal Building
Northampton, Mass. 01060
WOR CERIS COMTENSr 770N MSURANCF AFFM,,'LV1-j"
(Ii 0xlpermi ttcc)
�I.rlth a principal place of bu.siness/residence at:
-
(st/d ty/sutLrzi p)
do hereby certify, under tic.palm and penalties of perjury, 1121
( ) I am an employer providing tic following'tvorlcer's comocnsa , cove age for Inv
emplovecs worming on tltis job:
• (I-0S=-:m=Comp) (Policy Nu-mb-r) -- (r:-pirz oc Dzt`)
O I am a sole proprietor, geoeral contracor or homeowner (c cie or!e) and have hired
the con Tactors listed below who have the z1bbowiroQ woritie>'S comoen_�a�on pa!�cies:
0,;3rile Oi Con[:-.1C-,Or) (Instrallc ColnpaJz}'1f GhC{ ?��11II1L<I) �_tiJ1iJ QQ I�BIC)
- (Name of Conmczor) (1ns.>.[zncc Compa -wPOl1Ci \umc^r) (i»irat?n Date)
(Name of Con>s-acto-) (IZSul-anc; Company/Pol-q- Namb`r) (Expirdoo Dalc)
(Name of Contractor) GzSurmc- Comrzzy/Pobcy Number) (Expintioo Date).
(aIIarrl_d:+i::ocaJ�sca.irnc�ti--spry co a�cucL iafortn.loo pci.iai..ng to.0 c =-r..on) .
{ ) I am a sore proprietor and bave no one woridng for me.
( I am.a home vNvner performing all the work myself.
NOTE:plea lx awuc[fi*. Q-c 6cmeouvcrs�.bo splay pcoai eo =--z=oo r rrnu work on a d-xIL-F of
a.ot MOM lb--c tbs =t-j is inch the bomoowocr rgedc a ca the p-ound:,zppur,-m.�tb"",na c-"-ty oc"=d--w w be
ciiploy,=arid--the.. zi—cn=p,-... on At=(GO 52-=1(3))•=4p[ic=ion lry i homco..fcr--be-=of petnit-y-id—tl:e
lc&zl ctzau ores�loyx under drn Workda Compomitioa Aa-
[undc-gs d d d a Dopy or tbii mtcmcm n y be fordod to tbo Dopnrtmcat or lndussicl,1c+adc ofs-of t.>;ur.00e ror tb.
Cavcribc v-Tlcsica&nd t[t_t L-iltat to io .Lrc covcrybc under Ux::GOQ 23A of h(OL 132 c=[cd to tba i_v0s;2ioa orcimiazl pcazlricz
coosrsmg or ftnc or up to s1Soo.00 arzt,jjprisoon�or up to ooc yc-.r rod ci%il pay.Pja is Crc ro(m on Stop work Ordcr and a
flue of SI 00.00 a day LPIC31 CDC
For dcp.rtm>>u,c only
permit Number
�( O
1,/,z P." Lot
bigxatiur of Lic=i--, C/PCRSUUGC e
SECTION 8-CONSTRUCTION'SERVICES J
8,1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
lte istere Homf~:fin
r e
Not Applicable ❑
Company Name Registration um er --
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION 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...... ❑
I1 = ornEl�v >r � � 0
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 VAW L
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [C1] Decks [p Siding[0] Other[p]
Work Description of Proposed l<,I�Vp^ C'(� /�.�A��i��'1
Alteration of existing bedroom Yes No Adding new bedroom Yes No', e�
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa If=t�ev�:douse'�art' o�add�tio�#a��x�stcnc��iaustrea uco�pfete>fh`e-�foC�o�ng:
a. Use of building: One Family Two Family X Other
b. Number of rooms in each family unit: 4 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? f 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 _ }X 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 SupplyX
SECTION 7a-OWNER AUTHORIZATION.-TO BE COMPLETED.WHEN
OWNERS AGENT OR CONTRACTORAPPLIES FOR'BUILD(NG PERMIT.
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
UV wne uthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the beaftif my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print SN�
Signature of Owner/Agent Date
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Section 4. ZONING All Informatioh 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: R: L:
Rear
Building Height - —"
Bldg. Square Footage % a �-
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 Q DONT KNOW 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 DON'T 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 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 Q
IF YES, describe size, type and location: j
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 Q r NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
of NoftPampton to e
Department e
2 Main Street e. of tEE a�
?Room 100
04 N' pton;MA 01060 T Ssn~arur'niIa � �
e 41 -587 1240 Fax 413-587-1272 Pt�2
rhtOSTR jLa ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Thts b
section to e coin pleted by office
1.1 Property Address: '-
Lot ,Unit
r t� t 'S t -t,��'r� Zone Overlay Dtstrtct
EIn S�District ,CB D�stFlCt
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
G� lam/ Telephone ^ ( - -5`�(f
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 5, 0J 0 (a)Building Permit Fee
2. Electrical -3 (b)Estimated Total Cost of
Construction from 6
3. Plumbing U Building;Permit Fee
.4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) (t, U l)% Check Number
This Section For Official Use Only
.Date'
Building Permit Number'= Issued:
Signature:
Building Commissioner/Inspector of Buildings- Date
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File#BP-2005-0570
APPLICANT/CONTACT PERSON DUVAL PAUL H
ADDRESS/PHONE P O BOX 956 NORTHAMPTON ()584-5743 Q
PROPERTY LOCATION 11 HANCOCK ST
MAP 32C PARCEL 233 001 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: REPLACE KITCH CAB,APPLIANCES,2 WINDOWS&SHEETROCK
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
INF99MATION 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 Co ssion
Q� ZOO
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.
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11 HANCOCK ST BP-2005-0570
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32C-233 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0570
Project# IS-2005-0750
Est.Cost: $11000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa.ft.): 6751.80 Owner. DUVAL PAUL H
Zoning:URC Applicant: DUVAL PAUL H
AT. 11 HANCOCK ST
Applicant Address: Phone: Insurance:
P O BOX 956 () 584-5743 ()
NORTHAMPTON MAO 1061-0956 ISSUED ON.11/15104 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE KITCH CAB,APPLIANCES, 2 WINDOWS &
SHEETROCK
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 11/15/04 0:00:00 2169 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo