32C-297 (5) ..........
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n DEPARTMENT OF BUILDITjG 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 1-11s/her construction supc., . 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
t,a inspect work-at-various stages, which-include-fb_und _t o_n/_fo_Qtinzs (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 occupanev
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 roper permits and inspections are
1> - (J'Y� understand the above.
'(Home owner/residents signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
.ued to me.
Date
Address of work
location
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v~ Q DEPARTNIEI-T OP BUILD[No 11`ISPECTf0l.'S '
212 Alain Street Municipal Building
Northampton, Mass. 01060
WOIUCER'S COMPENSATION -MSURA2qCE AFMAV11'
I,
01 ccvs.-cJperrni It=)
VIritb a prMcipal place of businesslresidence at:
(phone!)
(sa-�tic�ty/statrlri p)
do hereby certify, under die.pa_ins and penalties of perjury:, ha l
( ) I am an employer providing the following worker's comocnsabor, cove zgc for InN,
eluplovecs worong on uiis job:
(Insur-an= Conn: ) (Pclic: Nu--nb--r) -- (T -pir`tior, DaL.)
O I am a sole proprietor, general cooa-actor or homeowe e one) d ae id vred
the cono-actgrs listed below wbo have the foUo%Ving worker's coc-.D:)tnsadon po5cies,
II+IIIIIC Oi Co.^.'::a0r) (111-urancz Colnoan yit-'cuc�
-- (dame of Coa racior) (Insw-anec. Comoaa}vPoik Nuncrr) (-Exp ,:lion Date)
(Name of Coaaacio;) ozsulanc COMPaDy/pOL-q- Nwnbc-r) (Expim6os Datc)
(Name of Coacaetor) (Imsurancc- Compaay/Policy Numbu) (Ex-pilatioa Darr)
(a[ia.cb ad.�s�ocal bcC,if nccoi�•to c,cu�iafortn.�oo pctuayns to.11 cc41-.�0�) j
{ ) I am a sole proprietor aad bave no one worizng for me.
' ) I am-a home owner performing all the work myself,
NOTE:pl=s be ew-.rc rh*• i:Jc hc,,,=,,ra wbo lay Pc--Io r w do cr rryau• orz o-a.d-U-,-Z or
Q0(meet t t.l:rrr_tmt'.r in a-Eeb the bomoo-0-r=d,=or oa th.c p-ouj e zppurtco:ri Ls=,ew ax 0ecrd7ai to be
cztPioycs uode the..a- `;—pa-- c.Act(GL15?� 1(5)),r_PpU=L6cro bf a hcros o-Dc far:6c-v oc permit r y e-rdczcc the
1,pJ n»„of=e=pleyW under do Work ,L Co apamitio¢Act
I uo ica the a oopy of thin m y ba for-deal to the pp,�,2 of I-i-rid A-d-&0lrioo of Ira noon roe ths
cova�sc vc'if c=d0a and the L--ilt-rc to some tovcry6,undcz z-e-n 1 S A-f?,((D L 15-1 can led to the iaP ca of=in i pcasltio
0003-mg or a Gx orup to S I X00-00 and/or of up to ooe ye eod cviJ p=n pja in 6c roan of a Stop Work Ord-- and a
run of 5100.00,d y t&irLa me
For dcgutr_�=.�u-only .
• •r:, � �( � � �crmlt 1�itunbcr
1�p:: Lot .
Sipa,-tcirrc of Li CnTiucc � -- j
SECTIONS CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
" Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCEAFFIDAWT,(M.G:L.c.f52,_§,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:Per-son-(s)-who-awn-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"homeowner"certifies and assumes responsibility for compliance with the State lding Code,City of
Northampton Ordinancet d Local Zoning Laws and,Ste of Massachusetts General Law Annotated.
Homeowner Signatur
SECTION 5--DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors X
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks ] Siding)411 Other[0]
Brief Description N�of Proposed ` C L• dj r' NV -%j++i�v.�S J`�"^`AAW
Work: I" 1�1 1�t CJ i' ,�/ �//"L-, /� ,j "� �� °--s
Alteration of existing bedroom Yes ^ No Adding new bedroom Yes r\ No
Attached Narrative Renovating unfinished basement Yes Z No
Plans Attached Roll -Sheet
6a hCeirt fro se of ad"d t�o674, a >ISf—" stria cor pet af[aW> g:
a.` Use of building: One Family �• Two Family Other
b. Number of rooms in each family unit: 7 Number of Bathrooms ,
c. Is there a garage attached? /'J
d. Proposed Square footage of nons'truction.�S Dimensions
e. Number of stories? s'
f. Method of heating? _Cry-� �[] t R�� Fireplaces or Woodstoves C'L. e— Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction ✓'J,�D
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
, s
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 _
SEGTIOW7arwOWNER'AUTHORIZATION TO BE IrEQMPLE:T;Et�1 HEN-
OWNERS':AGENTOR CONT;F.AGTOR,-APPLIES-FOR�BUILDING 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
r ? LJ as Owner/Authorized
7bereb�ydeclare Ag 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.
- ';rv\
Print ame
oil
Date
ature of Owner/Agent
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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 06a—,
Building Height n V'
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location) IL A Z/1
A. Has uSpecial Perm it/Vahunoe/Fi riding ever been issued for/on the site?
/C�1% ��
NO «�� DON 7KNOVV k�� YE3 ��
x��
IF YES, date issued:!
IF YES: Was the permit recorded uc the Registry ofDeeds?
NO DONTKNOVV 0 YES
IF YES: * enter Book Page and/or Document#,,
�� ��
B. Does the site contain abrook, body of water orwetlands? NO &�/ DON7KNOVV �_� YES 4��
IF YES, has a permit been ur need tobe obtained from the Conservation Commission?
Needs tobmobtained ~��~� Obtained �-\ Omta )ssumd.�
� �~/ .
C. Do any signs exist on the propert ��y? 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:
E. Will the construction activity disturb(clearing,gradingexcavation,orfi||ing)over 1 acre oriait part ofo common plan
that will disturb over 1 oono? YES y ) NO �*�
�� ��
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Qity of Northamptonfatrts Pe
Building Department � �. � a
212 Main Street ee yaifabrrs �� � � ;
Room 100 a r6 ela at ��
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 Palter � fi =
? � ��
°p . gSRecrt
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION`1-SITE INFORMATION:
1.1 Property Address: This.sectron to-be completed'4 office
Lot UnEt
s
ki ri r � / 1`� 20 :xA' rla'DEStdret
ElttZ'LiD frrct CB Distrrct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT-
2.1 Owner of Record:
l3�)r, G ► - r l N�'' `. i 14 f i�Ps'l !; , An,M P T&
N (Print)i ✓�� CurrentItajjing Address-
C2
�j
Tele n
� ne
7 co c
S nature 5 ,r 0 o.>_ l
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 permit applicant
1. Building (p)Building Permit Fee
2. Electrical (b)Esti mated,Total Cost of
Construction.from 6
3. Plumbing �hC) Building,Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 1 Check Number
ThisSectiom For.Offiicial Use.Only
_
Date
Building Permit Number.: Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2007-0436 CE U-
APPLICANT/CONTACT PERSON FINN RHONDA S
ADDRESS/PHONE 21 HENRY ST NORTHAMPTON (413)585-0017 Q
PROPERTY LOCATION 41 VALLEY ST
MAP 32C PARCEL 297 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out 4C4 y
Fee Paid
Typeof Construction: CONSTRUCT DECK NEW DOOR ROOF REPLACEMENT WINDOWS&REMODEL
KITCHEN
New Construction
Non Structural interior renovations
Addition to Existin¢
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
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 Building fficial 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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41 VALLEY ST BP-2007-0436
QlS#: COMMONWEALTH OF MASSACHUSETTS
; V:32C 297 CITY OF NORTHAMPTON
Lot:-001_ ; PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Pg ullding DO NOT.HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
b2iect# JS:M7:QQ0647
Este Corr.�27tNl�tDtlU
52s PERMISSION IS HEREBY GRANTED TO:
Coast,Cuss: Cvntraeror License:
used _' Homeowner as Contractor
Lot siggsq;fu: 609$:40 Owner: FINN RHOII DA S --
s -
AT 41 VALLEY ST
AFEltcant Address: Phone: Insurance:
21 HENRY ST (413)585-0017 Q
NORTHAMPTONMA01060 ISSUED 2N:11,11g2006 O.-go.-o0
TO PERFORM THE FOLL6* NG WORK.CONSTRUCT DECK, NEW DOOR, ROOF,
REPLACEMENT WINDOWS &REMODEL KITCHEN '
STf T IS CAN SO IT IS'ESIM FROM THE STREET
Inspector.of Plumbing Inspector of Wiring D.P.W. Building Inspector
,
�:e � i�leter
Undetg�¢� d : t c� °+ ,f ervi ce..
Footings;
Rough: Rough: House# Foundation:
Driveway Final:
Rough Frame:
Gas: Tire Department Fireplace/Chimney:
ROngh. Vie: ia.Swaataha:
Final: Smoke: Final: 6-Al—,07 --Q
THIS PERMIT MAY BE:REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS]RULES AND REGULATION
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