34-024 (3) ¢gtiAMA�
� � jlTlassachusetta -
r
Q 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 i:is/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 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 fegulations. 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, f u c��ti� � � understand the above.
(liolne owner/resident's signs ure requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date �4 S
Address of work /
location_
JIt
r
Cris 3 of1icr�fll��it}�to�� -
A ' E 3;c�akchosrUa'
d DEPARTME?,T OP DUILD0\10 INSPECTIONS
212 Main Strcet Nfunicipal DuildinG
j Northampton, 'Mass. 0)060
I ,
WOMCCRIS CONIMENSATION CgSURA-NCF- AITDJ:I.VD-
Ct
-- TM)tc'(I peI
%%rith a principal place of business/residencc at: ---
( f rkp i�� .� �orer1t.� 4/Dl�Z-(} hone') '/3 -6 �� v'
(Sac--Ucity/slates P)
do hereby certify, under d)c pa-ins and penalties of perjury, hal
I
j ( ) I am an employer providing the followint!%vorkc>'s coinocns-n:Jon cove age for lny
emplovecs Nvor�ong on Otis job:
OMS11_r--2*C Conr.M•) (Folic: Nu--zb^r) - ( :pirtior, Dzcc--)
I -
i -
I am a sole proprietor, general contractor o home6wMer c cie one) and have hired
the con-actors listed below wbo h2ve the foDowup, wortcer's Ca0oen'adon pabcies:
j � ��Y �aurh �raQLLS Me q .Ah a
('Name Of cony;".aor) (1--':JIid:3Q? bale)
-
(Name of Coun=or) (Las-.u- nc;. Companvi?ol—v Nuncrr) (tKDtr lion Date)
(Name of Conuacto,) CLa uaacc Compan)•/PoUq- Number) (ExPirtion Datc)
(N2me of Coaaaaar) (Insurance Comp
zay/PoUcy Number) (Ea-pi-,6on Dale) .
(.ate:d!i OC=J d—I ifncc=�-v w in ;ud inroc�oa P=-t ' to.0 eon-_'Z.o:-�)
( ) I am'a sole proprietor and have no one wor�3ng for me-
{ ( ) I am,a home owner performing all the work myself.
NOTE:plesc be ca-zrc tbt:v j )c bcc oco ocra vbo c=play pc=maw cn do n^- c,,raao Cr trna work as r of
i
mot meet than ' c-ta'r'j is ubicb the bomoownct raid=or oa Eb4 poun6 zppsrtca rt t6cen c c not —Jty ceerd rc�i w be
cirQloycs tto"c the wai crt c=x--..,.oa Pct(GUI 52-=1(5)) pplincioa by.ComoOQaa fa n Gc _or permn r=y--id—c>c
1c�ct x.'ur of ea ezplayer uodcr die WorkceL C.o@pcc ai;prt Ad
II t uoda-a..-tad tb,a:oopy of th6 cat®cat may be foc>. riled to the Dcgertcocoa of Inalrri J Modal'oT'.or 6- —for tb.
oova-aSc vc'if taboo a_yd lh i Lilts c to savrt tovcrase ttadr_r souioo 2 S A of h(dt S S2 can lad w t4c i�rssrua,aC�'°1t pCO`li'°
oem.tGmg oft rise orup to S I-500.00 utdlor 6nPr ioameri orup to ooc y=r tcd civil pcutia io tbac form o(a Stop Work Order.ad
ri=oC S t 00.00■day.�last me
jFor u. only -
I permit lhtmbc-r
1`L7p"
'-Lace }
Si turcotLianscclPcrsnittcc � 3171 0�
r �
SECTION 8-CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature - Telephone
Ze'ni MeE�or mp a erona` _ . � Not Applicable
I
Mc e Be rc��,l m�-�
Company Name Registration Num� e�r— --
A ��g�ons erne Cart
Addruessn
T Expiration Date
� �YS 'Q Ar4y1 OKC 1 aR Telephone-9/3- Y 3 1 7 q�
SECTION 10-WORKERS'COMPENSATION-INSURANCE AFFIDAVIT(k L:c.152,§25I
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...... 91"
'
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 and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of)¢assachuse7Geeneral Laws Annotated.
Homeowner Signature ,��
r
i
r.•
SECTION'5-DESCRIPTION,OF-PROPOSED WORK(check all applicable)
New House [] Addition ❑.- Replacement Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[O] Other[d
Brief Description of Propose
Work: n5L&& WP6 .S1o.'& and 5ta;n�t3s SfCI ��u2 rn ex.s]F. C
Alteration of existing bedroom Yes No Adding new bedroom Yes _,�No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa i l ew ox�se a �t c�rrto ex><s na octs�ng ,complete t ie f Q �n A114
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 v TO 3E COMPLETED,WHEN �,fl�
_._ . . _ .
OWNERS AGENTfiOR CONTRACTOR 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
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 � J
ge Date
Signatu of OwnerlA
r •
Section 4. ZONING All Informatiiih 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
fff I i
Lot Size
Frontage I
Setbacks Front �!
Side L: R:= L:__? R:= T�
Rear
Building Height
Bldg.Square Footage I % (--
Open Space Footage �_ r-� %
(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 0 DONT KNOW YES Q a r/ ,t� �`����'J
IF YES, date issued: i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book I Pages and/or Document
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued: tS 4'3
C. Do any signs exist on the property? YES NO 0
IF YES, describe size, type and location: A SMall sr +7 4401d, �OaA00 trn Q try ' �h
Trod- ac '(fie ko c3�,��X J Ivu�to ' /0 '�c�ic's
D. Are there any proposed changes to or additions of signs intended for the property . YES0 �.
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 ,. NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
it
t of NortF ampton
Building Department
212 Main Street
.y
8 2005 i,,,% °Room 100 ,
Northa pton; MA 01060
L --phgnel 41 $-587 1240 Fax 413-587-1272 -
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This secttan to be completed by office
r
C! j;,u r key i�0 S C� Map Lot �Jni
,
j!fCf-?n�.� .� �Z'one °�` I � OyerlayD►sfrict�
Elrti S1 District
SECTION 2-`PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
e E. , l enkr wn d A Pet e Ks it 9 r-w►-Ire g t1t 1'add l areoce ,444 Ae<,t
Na (Print) Current Mailing Addre s- �-
1,4 Telephone
3igf.atuie
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 ;(a)Building,Permit Fee
2. Electrical (b)_Estimated Total Cost of
Construction from.6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) I ii
5. Fire Protection 11,0 0
6. Total=(1 +2+3+4+5) Check Number "
This Section For Official Use Onl
Building Permit Number ' Date
:Issued:-
Signature: r
Building Commissioner/Inspector of Buildings Date
119 TURKEY HILL RD BP-2005-0838
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 34-024 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0838
Project# JS-2005-1163
Est.Cost:$2159.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa. ft.): 148104.00 Owner., HOLLENDER FAYE E&CYNTHIA PARKS
Zoning:RR Applicant: HOLLENDER FAYE E & CYNTHIA PARKS
AT. 119 TURKt r' HILL RD
Applicant Address: Phone. Insurance:
119 TURKEY HILL RD (413) 584-0848 Q
FLORENCEMA01062 ISSUED ON.3/8/05 0.00.00
TO PERFORM THE FOLLOWING WORK:INSTALL WOODSTOVE
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: SK —'-;s -05 —&
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupang Signature:
FeeType: Date Paid: Amount:
Building 3/8/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo