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DEPARTMENT OF BUILDING INSPECTIONS l�
INSPECTOR '212 Main Street • Municipal Building
North.unpton, MA 01060
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: , isor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,a one or two farm __
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-6ui1 mg department fo—the"City of Northampton_wants-any personts)-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/foofines (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
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
Address of work
location
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a DEPARTMEI-IT OP BUILDING INSPECTIONS -
212 Main SLrcct Municipal Building
NorLhampLon, Mass. 01060
i
WORICEI IS CONI[PENSA770.N MSUItA�Clr AI'}'D�A.1�1T'
(liccnsxJpc:mithx) _. ---- --•
,VI Lb a principal place of businessfresidence at: --
S 6 U t avcCjcl4L 4Zj Ione'}
(SO-=Vci t•J/a=rlj p)
do hereby cerdfy, under Lhc.pa-ins and penalties of perjury, _hat
an employer providing die iollowine''%.,orkCr 5 cotnocasadon cove-";c for lny
emplovees woriong on this job:
(Lntn=u=Comp ml) (Polito NiL-nhcr)
i
O I am a sole proprictor, ngeneral contractor or homeowner (c c:e one) and have hired
the consactors Gsted below wbo have the folio top, workers comoen_taaon pakies
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(iamc Oi Co„=CiOr) (InS�i3nc Cott1D1J1}"/�GUCi }�t7]Q1 CT) [r'-JI+J�Q ��11C)
(Name of Coaa-aczor) Qnsarane;.Comp_a w?oUm, Numcrr) (—E»ir 6on Date)
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(Name of Co=MC-167) (Lasuraacz Comfy/Pout}” Numbu) (E-xpirdoo Date)
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(Name of Coatraelor) (=Ura.nc-- Comra_¢y/poucy Numlti`r) ( apirtlon Date).
(aL•�C:1:d3i'.:oc3]r3cC if acca+.^v to mcu,43--iafort-t,.=�oc P-% icing to.0
m-a sole pFOprietor and bane no one working for me.
( ) I am.a home owner perfon=g all Lbe Nvork myself.
NOTE:plee be cw Nc r+,. !-}e hemea++acs..yo esptoy pe c oas to Li c�a;-• cs=oo e rcpo-u.,rock 00
aoe is-b h tb.c bomeo we raid.or oa the p ouac4 z7purtcn:.=tb--,c:we C�.r..lty o�cid-sd is be
enployt_ uaGe the.=km'z -,m An(GLt1 52 a 1(5)).=t'pU=6m b-f s bomco -=fc c 6e-.--or pcn m =),�-rd=cc tL-c
Ic-,r c= of ea—Ployx uodor tbo W.,koea Compomation Act-
t mad tlaa a-IVY of tbia ^mcm o y bo f----d-4 to tbo Dopn�orin&st d ncodcsa. CC—of lrau—for tbw
covcrlsc v=T1eoioa and t2u L-iltat w seeurt'cov�rase tmdc sceLion 23 A of 1.toL 152 m 1�to the iar ioa oI e;,,.*,.,t peoalties -
ooaT•i^a8 of a Gnc of uP to S I So0.00 sztdfor oCup to ooc y-,_r xad c�i1 pm+.hin is 6c form oC.Stop Wort;Grdc sad a
fire oC S 100.00 t d:y Lpiast me
For aQ.ra.:.�uK only
Pcrmtl Numlx7 _ —
(� � 7 ds I t,'LZP^—_ lot R 1
t-tofL1c=-Sr_lprrrn i t f nn
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SECTION 8<-CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
S:Re isfere `w ornmr me�rGant acn' Not Applicable ❑
Company Name Registration Num er -----
G� �► WIG C l� �! T�iv Zo 6
Address Expi ation 15ate
Telephone-574 h?/-7—
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVITIM.G.L c.152,,§25C(6)j
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.Aperson 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
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SECTION-5-DESCRIPTION OF PROPOSED WORK(check'alt applicablei
New House ❑ Addition ❑: Replacement in Alteration(s) E-1 Roofing 0
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs (0] Decks Siding[a] Other[o]
Brief Description of Proposed—"
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
tia !€Neviioirs�andaddrt�aaextst�n. �oisetccopeffefftCaFna:
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
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
SECTION 7a-OWNER AUTHORIZATION-TO BE-COMPLETED WHEN
OWNERS AGENT OR CONTRAtf kAPPLIES FOR BUILDINSPERMIT
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
K-- a as Owner uthorized
gen ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my nowledge
e ief.
Signed under the pains and penalties of perjury.
Print Name
Signatuf Own ent Date
Section 4. ZONING All Informatibit 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 E '
Setbacks Front
Side L: R• L:� 7 R:°
i I
Rear
Building Height
i
Bldg.Square Footage 1
Open Space Footage %
(Lot area minus bldg&paved I I
parking)
#of Parking Spaces
Fill:
(volume,&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
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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 iI Page; and/or Document#:
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Date Issued: k
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO i
IF YES, describe size, type and location:
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 O r NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
� A `
f, City of Northampton
Building Department
212 Main Street a ei
Room 100
Northampton; MA 01060
phone 413-587-1240 Fax 413-587-1272 Ptt7S1 ins
0the ee1fi � ' `
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Th1s sectron to be completedG byoffice .`
1.1 Property Address: _
Nlapr, °L:at s'_ ��lJnitP "
Zone Overla(District
VA't__(_
EItrSfa District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: �l
�_1) YI!1
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
to a Telephone
SECTION 3-ESTIMATEI3-CONSTRUCTION COSTS
Item • Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee rl"v
2. Electrical (b)Estimated Total Cost of q6 �'O
Construction from 6
3. Plumbing Building Permit Fee.
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) ��y S U • ' Check Number 2-12-16
This Section'For Official Use Only
Date::
Building Permit Number.~ Issued:
Signature:
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Building Commissioner/Inspector of Buildings Date
File#BP-2006-0589
APPLICANT/CONTACT PERSON John Corbett
ADDRESS/PHONE 56 Dimock St LEEDS (413)586-8712
PROPERTY LOCATION 24 VALLEY ST
MAP 32C PARCEL 294 001 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 `LS-47-0 -2— Z
T_ypeof Construction: Replacement Windows
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included•
Owner/Statement or License 104000
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 Commission
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.
24 VALLEY ST BP-2006-0589
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-294 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildin4
Category: BUILDING PERMIT
Permit# BP-2006-0589
Project# JS-2006-0865
Est. Cost: $4650.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq.ft.): 6795.36 Owner: FISHER ADAM E&ELIZABETH R
Zoning:URC Applicant: John Corbett
AT. 24 VALLEY ST
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON.1112812005 0:00:00
TO PERFORM THE FOLLOWING WORK.-Replacement Windows
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• Date Paid: Amount:
Building 11/28/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo