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\ DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR '212 Main Street • Municifll 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 l:is/her construction super.,isor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which lie/she resides or intends to be, a one or t 6 fame-__
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
ade
/Z,�,ye CL: 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 t�� -
i
I - '
¢�iw-rn�. r.. •
20
of Porflic3111plon
9 J f Rl93akchnrc Its
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u.� DEPARTMENT OP DUILDD\10 INSPECTION'S i
j 212 Main Strect ASunicipal Dwid;ng
Northampton, Mass. 010GO
,! WORtI:R'S COIAT NSATTON MSUR�NCE AFFM�iVI
i
I
j (hccas:Y Pcrmjltcc)
nth a principal place of busioessfresidence at: - --
(phone')
� (SII�.t/ci fj/Staic��p)
do hereby certify, under the.paint and penalties of perjury:, :hat
( ) I
an an employer providing die following worker's comocnsabon cove m for Iny
I emplovices worUng on thus job:
(Incur-mac Con=c.) (PCUC-. Numb-cr) (T:pirzdor. Dom)
( ) I amt a sole proprietor, general contractor or homeowner (c cie one) amd have hired
the coon-actors listed below who Have the following workes comoensaoion policies:
(Namc o,- Co?17acior) (Ins_r-anc;c COInpaPyi-tlobC{ Datc)
(Namc of Comte ior) Oas-aranc: ComoanwPolim, Due)
(Name of CO=CtO:) R surancz C.ompa.o y/pobcy Numb�.r) (Expirstioo Daic)
a -
(N2Mc of Contractor (E� iradoa Darr
j ) (insurance Comr.�my/Policy Number} t � ).
(aaxb adu�ocal r'�ccf,if ac ate•
to me-".�=afortni-ioo pctaiaia,6 to..0 coo?-to^a)
1 O I am a sole proprietor and have no one worming for me.
I am.a home oNvoer performing all the Nvork myself-:
I J` �' ' "'
NOTE:plea be ewlrc rfi,,M e bcmcov�ticrl wba,ctplay➢CLOGS Lo �,—acuoo c naaa warz on a d..cl!_Z of
aat mxc tb a tamer tmrr is«•bid the bomoow r=ido or oa the aoua rpputteo-rte tba--D t- oo(C=>=Ily oL=.d--cd to I?c
eitpioyel uric c the o=p,—. m Act(GbI52•n 1(5))�:pplin600 by a bomc %-na fcr L Grp=or pa=rt cr=y ctiidmz the
Ic-gal cts.au oC w e=Ploy.r uoder dLO W.+i e.Comaomat Act
[—dczr.aad ib.d a copy or cbi.ear.emr.a may b.for�.nrddd to the Dep.nmeo¢of ro.da.xricl Ao &a Office of to=s+r•�ror th.
ooverase w esuoo aad Uc:i C iltat w savrc eovery�taodc soetion 23A of?{QL 1 S7 m lr_d to the i i2ioa o(eimiall pcatltia
°O°3i=m8 of a Cxae oCt�b S 1}00.00 arldrOr oCup to ooc yur e.ad coil pmaltia is t`s form o(a Slop Worti Ctde aad a
j f=of S 100.00 a day aptia4 me
-----
For d�.rts u+ Only
Pcrmil Numbcs
)',/La P."-- Lot
i
/M.tumofLi crmiucc e / ` .J '
SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
2ea►sfeifom` naarm ementco, Not Applicable ❑
Company Name m
Registration Ru —br — -—
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE;AFFIDAV-U(M:G:L.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...... ❑
11C� a �ijartllfl
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-vear 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 d assumes responsibility for com liance with the State Building Code,City of
N hampton Ordinances,State an cal Zoni ws and State of M usetts General Laws Annotated.
omeowner Signature 'L
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'i
! ti
SECTION 5-DESCRIPTION OF.PROPOSED WORK-(check°all'anDlicable)
New House Addition Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. Demolition ❑ New Signs [p] Decks [p Siding[C7) Other[E
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
Sean, i#o�texis#r<nc�~Ciosl6a. arxrplQteh` 01wng:
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
L 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 74-OWNER`AUTHORIZATION TOBE COMPLETED;WHEN,
OWNERS AGENT:OR'CONTRACTOR APPGIES:I=OR'BUIL DING:PERMIT
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to authorized by this building permit application.
Signature of Owner Date
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.
Print Name
Signat re of Owner/Agent Date
Section 4. ZONING All Informati6n 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 l ; I
Setbacks Front � 7
f Side L. R:' � U- f
4� t
Rear
Building Height ----
z
Bldg. Square Footage %
Open Space Footage . %
(Lot area minus bldg&paved
parking).
#of Parking Spaces
Fill: r i'
(volume I&Location
A. Has a Spec" I Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page; and/ ocument#'
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 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 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavaf ,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 r NO
l
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
P �
City of Nortompton
ui ',�g�epartment
' 12 Main Street �
V' �'Rd= 100
N harnpton; MA 01060
ph2) 4� 587=124 Fax 413-587-1272
APP Tfi4�TION'Tb'C N TR�8�T,ALT R,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE-INFORMATION
Thins section to be completed by office
1.1 Property Address: � ' '�/tr�t7O��( `� t � r k K
l/ t I
f�
Zone� OveriayDisfrmct
Eltri SL Des rct are CB Dis#rrct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
L)
Name U0 i�
� � ; �`" lNi 1��=E� Y��ir�
Name(Print) Current Mailing Address:
Telephone
Sign ture
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 app licant
1. Building ;(a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6-
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number I
This%Section For Official'Use Only
Building Permit Number.` IDssued:
Signature:
Building Commissioner/Inspector of Buildings Date
s
File#BP-2005-0883
APPLICANT/CONTACT PERSON PAINE KIMBERLI
ADDRESS/PHONE 54 OVERLOOK DR FLORENCE (413)320-2220 Q
PROPERTY LOCATION 54 OVERLOOK DR
MAP 29 PARCEL 190 001 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 71ZT NET-
Typeof Construction: ERECT 6 X 6 SHED
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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9&MATION 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.
54 OVERLOOK DR BP-2005-0883
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 190 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0883
Project# JS-2005-1218
Est. Cost: $750.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 23478.84 Owner: PAINE KIMBERLI
zoning: URA Applicant: PAINE KIMBERLI
AT: 54 OVERLOOK DR -
Applicant Address: Phone: Insurance:
54 OVERLOOK DR (413) 320-2220 (�
FLORENCEMA01062 ISSUED ON.3125105 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 6 X 6 SHED
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: QA- 7--/,2 4 y
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. _
Certificate of Signature:
FeeType: Date Paid: Amount:
Building 3/25/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo