29-379 Crztp of Xort4ampton L
�i a55RChItSttt4 �
GR\
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 780CMR 108.3.4 to
act as his/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
1, 1 understand the above.
( me owner/resident's signature requesting exemption)
call to schedule all required building inspections necessary for the building permit
issued to me.
Date 1 100
Address of work
location
F(O .nCE, Mk 01060
o ti
� 6 h�cssxrilnsrtle '
L)EPfu2T?iENT OP LUILDI)�G INSPECTIONS
212 Main Street ' Municipal Building
North aulptoil, Mass. 01060
WOPUCER'S COMTENSATION INSURANCE AFFIDAVIT
principal place of bu�itiess/r��sidence t:
(Sircz C cit,fi;; YT)
CIO do hereby ccr-tldv un:Jer dic• vans .Ind penaitie,; o�per�ur�t tha.?_
I aiT1 a i cmpioyCr providing the `or II7y
cmployces worting on this job:
(Ins x=cna Company) (?e c,Number) _ (rxT,ir::tion Date)
O I a-z1 a sole proprietor, g.enerLi con.:M cnor honneowver (ci;cic one) and ;we hired
the contractors ListeC beiovy;>ho tine :010 0Fkers coc pen�adon ;:�o!!c��s:
(T:amc of Contractor) � (In_ur:lc Cclr ;;;PclicJ 7' snl�r) Wit: ratio: Datc)
(Name of Contncto:) atioa Date)
(Name of Coatracior) iT1S 3I1C^ C:� 7 a :il�OliCj l l7II]J� r) '.X4;ir 1,at'')
- (Name of Contractor) —- (Insl=1c- Comr YIy 1 oLicy Ntrmb_r) ._ (E;:ni:-,:tic - Dare)-
(CIt.1C1:.L�'�It:M1)5:.-<t......_... ::� ...-_.....-...:-•c�..,_". ,- ._..-. -.il.�-�.-._:.-...-.1
LII <i 1 I l 7v-c
il<. i 10 t0i
iIl i 1:UiI]C C1'i?1C" IiCiIC`i??111 , all is":.
NOTE:pJczsc be awa;c L'a:.5'.':]C F,«;couirs
not utcee th_n three uni,I is wL'dt c:c o-{Cc rralY,i cr :':r:c :o h
c:Iploycs ur�t}r.tvcrS.cra ccrx--:airn Ax'((7jI.1,2j(5)), .=a;ic::Lv s hnrrm« cr`cr a I cc:x or
ItS11 ctatua of an c=ployx unur t::n Wozkcez l a^;ur.tion .ct
I undc.stassd th, a copy of th,ct>tcz s�r_ay bo faw.vc!ed to[!»IYtxvtz cn of?i BLS rii]AtiiL�tj CiL w of t: ra_r-o for tlx
cov=gc vcrificziioa and that f_.iJtuc to:--u- 25A cf.'.IGI.152 can lad to the ioTpositia of r i 1 pasl;_cs
oomtstmg of a fur-of up to S I.-M.00 iin�'ff of t;p to crl-}- r.-.J civil pc:u1jca in dC fcnn of+
firm of S QQ.QU a day i;!-itrt m=.
Fcx-ciq%utsTn:11 u.e o.i7y
PgrInit
-n-- Ill
S ' . Irc c
SECTION 8. CONSTRUCTIjON SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable
�9'�Reg s e am '"mpro�ern�rit�`Contra�tor- � ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 VYORKERS' COMPENSATION INSURANCE"AFFIDAVIT(M G:L..c 152, § 25C(6))
N,
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_s_upervisor. 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 far 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
SECTIONS=DESCRPTIONOEROPOSED WORK checkll a ticable
,»:.:�.±ms...:........._ .�nv.mw,md,._ ._ �;�m�a�.+ra�!:,�^�._ -•,.�,..z...M...,. ,+�s4nc xn..�...„, _,...„„x�x�:,.'�.���tt.;
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other
Brief Description of Proposed Work: CL6 C111--4.11 X
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes ✓�No
Plans Attached Roll J&• Sheet 0
Ca�1= ew�: ouse nd o'704'ition.Itoilez,st�ng:housi`ng. comple a the following:
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
SECTIOT[7 ��OlNNERAUIORIZATION TO BE COMPLETED WHEt3
OWNEkSAENTORCONTRACTOR APPVES:!fORiA UILDING PERMIT
I, 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.
� l a W —
Print Name
JSignate o ner/Agent Date
� i
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
�?Oo t"-0
Frontage
i a 6 10
Setbacks Front
417 20
Side L:X?- R:A,3• (o Le�����tR:.;Z
Rear 1 9 30
Building Height )—2
Bldg.Square Footage I
Open Space Footage �( %
(Lot area minus bldg&paved / ' 2 �jt��� ��� 6, 60"90
parking)
/ (�/ V
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Z DONT KNOW YES '
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or . Document#
contain a brook body of water or wetlands? NO DONT KNOW
B. Does the site Y
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 V
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:
Q f rthampton
BUil epartment
r 7 2004 21 n Street
SEP
00 100
No pto MA 01060
-1240 Fax 413-587-1272 y
AP CATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION;
t J d by offihis son mlete
1.1 Propey Address: ce
�e
z6
R-D
N1a�s 1.ot �` � Unit
�
t-'I t 1 tom✓ M O /p Zone Overlay Distnct
E�[n Sfi.,D�$trict z "" 'CB`Drstn+ct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED-AGENT
2.1 Owner of Record:
�T AIL Celia, Ma,�l��rw,90 GI
Name(Print) Current vg f� r�e
�,
Telepho e �
' ure
2.2 Authorized Agent: l� j
Name(Print) �— Current Mailing Address: I '
1 J
atur Telephone 3,,Zo —
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Offdal.Use Only,
completed by ermit applicant
1. Building (a)`BUlding Permit Fee
8 ooa . o 0
2. Electrical (b);Estimated-Total Cost of
Construction from 6
3. Plumbing — Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (I +2+ 3 +4+ 5) D p D Check Number 7
This Section For Official Use,Only
Building Permit Number: �7 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0273 • •
APPLICANT/CONTACT PERSON BOU JOSE'O
ADDRESS/PHONE 261 FLORENCE RD FLORENCE
PROPERTY LOCATION 261 FLORENCE RD
MAP 29 PARCEL 379 001 ZONE URA
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: ENCLOSE CARPORT
New Construction
Non Structural interior renovations
Addition to Existin¢
Accesso1y 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
INFORMATION 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 ion
�
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.
261 FLORENCE RD BP-2005-0273
GIs#: COMMONWEALTH OF MASSACHUSETTS
:Block:29-379 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-2005-0273
Project# JS-2005-0357
Est.Cost: $8000.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin Homeowner as Contractor
Lot Size(sq. ft.): 14984.64 Owner: BOU JOSE'O
Zoning.URA Applicant: BOU JOSE' 0
AT. 261 FLORENCE RD
Applicant Address: Phone: Insurance:
261 FLORENCE RD
FLORENCEMA01062 ISSUED ON:919104 0:00:00
TO PERFORM THE FOLLOWING WORK.-ENCLOSE CARPORT
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 9/9/04 0:00:00 1076 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo