34-027 (4) p4-�tif+MplO
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` DEPARTMENT OF BUILDrNIG INSPECTIONS /=
INSPECTOR '212 Main Street • Municipal Building '
Northampton,MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as his/her construction sup,y:,.- 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 amz y --
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 bTil Ing department for the City o-f Northampton wants-any persons)-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
requ ed can DELAY the project until such time as the proper permits and inspections are
e
I, 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 J E .61 a,aKchnsrtla'
j DEP/,.RTmEI1T OP BUILDD\jG INSPECTION'S
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212 Alain Street Muntupnl Building
Northampton, Mass. 01060
WORIa. 1Z'S COivfPEMSA'nON 04 SURA-N CE AI=I A ITT-
(li ccnsxlperm�rtcc)
�1-11th a priipal placz of businessfresidencc zt: ---
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do hereby certify, under thc.pains and penalties of penury, hal
j ( ) I am an employer providing the followinz'v.,orkcrJ5 colnocnsador. cove Mac for Iny
emplovccs ivoriang on tills job:
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i (L.=-nt; Com -z) (Polio: Nt=��^r) -- (r;-pirz or. D21--)
O I am a sole proprieror, general contracior or homeow-Der (c c:e one) a>ad have hired
Che conuaCgrs listed below «bo have the followijog Worker's G7mmOePt26on pokles:
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(N1-amc of Contnc or) Coit1D1f1)'Pt�GUCi NUJIL-:7) (r';?i.-auon D.Itc)
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(Nmc of ContTaaor) CU3-7 ra.ncc Comoauvi?obm, Nunb-:r) (E:;Diraon Dale)
(Name of Coaamelo;) (lnsuranc;. Compam)-[t oUq- Numbzj) (Lzpira600 Dalc)
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(Name of Conaamor) (Lnsuran= Comramy/Pobcy Numb`r) -piruon Date).
(ar�cb �ocsl tuc.irncec,_�w c cucE imfor=AEOo to.11 coc_co a)
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jO I.am-a sole pr-opfietor and have no one working for me.
( } I am,a home owner perfor-r=g all the work rnyself.
NOTE:pl=.=be avcart tt`••,,Lij bc�^awacrs u,jc�o c=ploy p,=-oa=to di e,^^l^ c=..:c,00 c rcpair work on a d,,,-U—'--t of
txx mcce tbrs L--v_—,,in loch the bomoo.+vc rrsda or oa the aou D6 z,pur tra_=the—o�z ox .11y=--.d--td to be
atployca u--'-c the wAI c{; --+'co Aa(GL115'2-=1(5)1 c.aptiaSoa by a bomco-=fc a 6c--oc pc.-mil m=y�46�t1-
Icgal C-"^ of en c=plcyx uodar da Wackt '.coc=omaSioa Act-
[uDJct t a Dopy of tbi.cstcna may be f r.-,dsd to tbo Ofs—of I—for the
coveio^c veirc=tioo cad ti=t L-iltam to L==tov�At a un&===Joa 25A of 1.101-152 can I-d to the i=P=iioa of='mica!Pca-%W`
oo�of a floc of up to S 1 500.00 andror
firr or 5100.00 a d y e�ioIl tzx o(up w Doc ycr ead 66.13 pmahia is 6c fccm or.Slop Wort O do sad
I For d,,.�ua only -
,- Pcr1>vt NttIDtX7 —
Signasurc of Lic=cs=/Pcrcniu= Date
SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9F Reere"iliroem°"ro. n atro
=�"��-�° Not Applicable ❑
Company Name Registration Nlum er -- - --
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION`INSURANCE AFFIDAVIT(KG.L.c.1-52,,-§2k(_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: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 be/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 Lays 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 all applicable)
a
New House F--J Addition ❑ Replacement Windows Alterations) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [E:3] Decks [Q Siding[C7] Other[0]
rief Description of Proposed I . -
Work: .[r. a V--) (D cX)CKDA Y n I V\Cti k--►f� �`�LL2 1 VlSCV, ,
Alteration of existing bedroom Yes_"I,' No Adding new bedroom Yes ?� No
Attached Narrative Renovating unfinished basement Yes _X No
Plans Attached Roll -Sheet
saFlf,#NewYiOrxse an ladd «toxistiitc>KiO:uslntt.cor►�peteMe o iQU�>tnu:
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNERAUTHORIZATION=TO BE.COMPLETED WHEN
OWNERS AGENT OR 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
I, 17GL'�'Y1'C►i 0. as ri eyi 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.
LL �� ;
Gt.TY i G.i 0.. Q r Q.1rl
7 P'nt Name
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Signature of Owner/Agent Date
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Section 4. ZONING All lnformat.jbh 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
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volurnel&Location)
A. Has ia| Penn�/Vuhunce/Fndi ever been �suedfor/on the sbe?
NO 0 DON7KNOVV 0 YES 0 �
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO K J DONTKN0W 0 YES
IF YES: enter Book Page' and/or Document#!
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B. Does the site contain a brook, body nf water orwetlands? NO �~� DONT0UOVV �~� YES �~�
IF YES, has permit been or need tnbe obtained from the Conservation Commission?
^
Needs tobaobtm[oed »�� Obtained �~� 0atm �ssued�.
��� �~� '
C. Oo any signs exist onthe 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 0 NO 0
'
IF YES, describe size, type and location:
E. Will the construction activity disturb grading,excavation,or filling)over 1 acre oris it part ofa common plan
that will disturb over 1acre? YES K j ~-~
NO � @
^~� }
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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g Department use anty
City of Nortf ampton
Building Departments . a
212 Main Street t
�L v
Room 1,00
_Northampton; MA 01060
phone 413-587-1240 Fax 413-587-1272 r �' � �.
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: ': This section to be completed bx office ;' '
p ( ,
0 -�t� {C Q I�C1 �1VIap �' Lot tiny
t �.Vl( f i Zone _Pi!
`DIS ICt
7=1m 5 Distract - :" CB �stnct
SECTION 2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
wvla I `, hr ;CiC,, C> "f3vie.� Io,- Turk ( IhI1 rev��t? .I�c�
Name(Print) Current Mailing Address:
C(.. (J, fK.� Telephone
Ll Signature
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 PermitFee
4. Mechanical(HVAC) 3
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
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.'Dater
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings- Date
102 TURKEY HILL RD " BP-2006-0832
GIs#: COMMONWEALTH OF MASSACHUSETTS
P:Block:34-027 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0832
Project# JS-2006-1280
Est. Cost: $3600.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): Owner: O'BRIEN TIMOTHY&PATRICIA
zoning: RR Applicant: O'BRIEN TIMOTHY & PATRICIA
AT. 102 TURKEY HILL RD
Applicant Address: Phone: Insurance:
102 TURKEY HILL RD (413) 586-7363-0
FLORENCEMA01062 ISSUED ON:212312006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL FIREPLACE INSERT
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 2/23/2006 0:00:00 $25.00397
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo