35-043 (3) of N artha ptan
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ss DEPARTMENT OF BUILDIT;G 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 l:is/her construction super vi,sor. T he state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be,a one or two fami�
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 ftulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backflll),
sonotube holes (before pour), a rough building inspection(before work is
concealed), insulation inspection (if required) and a final building insyection.Jhe
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, 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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F Crif� of �\Torfl}aiitpfon
R f R?aaaRchnsctla' _
DEPARTMENT OP BUIL00\10 INSPECT701I'S
212 Alain Strcct Municipal Building
j Northampton, IATncs. 01060
-- - «'ORICI RIS CO3YtPENSA'n0N GAS CE A=AVIT
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1 yc'�c�T 5c tr -
t%rith a principal place of businessfresidence at: -- -
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hone.')
(sa=t/ci ty/RRLcrn p)
do hereby certify, under the print and penalties of pc9ur., -hat
( ) I = an employer providing the following!worker's colnpens_nbo, coverage for !ny
emplovees worong on utis job:
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(Lanu_nc Coar ) (Pclic:Nu-�bcr) -- ' C :-piratior. D2j--) '
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( } I am a sole proprietor, geoera] coon-actor or homeowner (ci c:e one) and have hired
the contractors fisted below wbo have the fobowioQ workers compen_,,�_fion policies:
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('Namc Of Co„-^ci0r) (Ir1Rrntic—c Coinoan)-POUCi Numb-c') -''J1r1 tQ Datc)
(Name of Contractor) (Lnsur-nc:. Comoan-wPol.in, Nunc_r) (»u Lion Date)
i (Name of Coamclo,) (Ins1>r-dnc Compare}•/PoU-q- N=bj) (ENpimdoo Date)
I
(Name of Contractor) (LOSUrmcz— Com. auy/Poucy Numbcs) ( rzaoa DaLc) .
(aaar_b a.d'tin--Deal txd,irncr��_-�-to ine'u�iaforna.7oo pertn.iaiaS to.11
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(v� I am a sole proprietor area have no one working for me.
( ) I am..a home owner performing all the work myself
NOTE:ply-=be ewzm o,., bcm=Cft�vm ubI0 csnplo-y Poona LO dD% •= c=r�_•:euoo cr repair wor c w c d%%< -•Z of
ant mots t a '� tmLr is I-b36 the bomootwcr raid.oc oa the gv=43 sqpurtcn_s tbeen c:T Ox E--n—UY c,-=6-td to be
aitploycs unl a the- -i:da c=P--*ten Act(GO11 Stn 1(5)�=Wtia6ca by a bomeom-=fc c lie._-or Pamir r=y evid=cr the
lc-pr ctaate or ea e=playw uader ttso wok e,CoeaPom.tioa/,a-
i - I unda:tiaa that a Dopy of th;,etZtemcm m.y be f«-�.orded to the DeQectmeoa arind.+xricJ ncodet�'OfGoo or trr.+r•o�row w. .
covazg c weir-lino read ahh.t Ui -to saws'covcrttb-e tmdcr soccica 23A of MGL 152 c=tad to the i=p=S Oa of aimiaa!pea ztrica
coa icing or a rrae or up to s 1 Soo.00 erwor of up to Doe ycr ead civ)penaroa in cbc focm ors Stot+Wort;Order sad
firm o(:S 100.00 a day tgxima mc-
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Stznaturr of crrnittct e
SECTION 8-CONSTRUCTION SERVICES c
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: 4'a /Z'A 7
License Number
oro�5 3
/�O�3 D,� /off /// G✓/T A. STezrr�_..-�'L.�szv s./h,i>+
Address Expiir—a�'i not Date
Signatu � - Telephone
; teen re > E Not Applicable ❑
/zp � V,5�
Company Name Registration Nunn er ----
y/NT� �rr Si iuo�✓ Z7/c4/o 6
Address j Expiration Datif
a6�4 Telephone J` fV"x/752
SECTION 10-WORKERS'COMPENSATION INSURANCE"AFFIDAVIT
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...... ❑
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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 108.3.5.11
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-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 be/sbe 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 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 amilicable1
New House ❑ Addition ❑- Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[O] Other[j (
Brief Descriptiorr��,,.gqf Propposed
Work: ;RCGL��Y/�/fL `�//G5 A/YO 1� L*' AAA 41:3 ok- 4,q-?��
t � y Renovating unfinished basemen � Yfs
�17rhf lvr - - ��.�
Alteration of existing bedroom Yes No Adding new bedroom Yes No No
Attached Narrative
Plans Attached Roll -Sheet � iiTs
sa'- ��haas�an> d��ia��c�ex�st�ii oastng,�c�Iri�pletethe�o (awrnu:
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 7a-OWNER AUTHORIZATION TO',BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPUES_FOR-BUICDIfV PERMIT
I? jj�jT ��,g f/ _ ,as Owner of the subject
property
hereby authorize Z4 12-X-y
to act on my be a i all m tters re tive tow this building permit application.
Signature o Owne Date
®���, —�` as Owne uthorized
Agen ereby declare that the statements and information on the foregoing application are true and accurate,to the best of my know edge
and-belief.
Signed under the pains and penalties of perjury.
14 2 ✓�L=�T 5Gh
Print Name
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Signature of Owner/Age 6 Date
Section 4. ZONING All Informatioh 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 I I `
Setbacks Front
Side L; R:' ' L:' R:=
Rear
Building Height
Bldg.Square Footage --I %
Open Space Footage %
(Lot area minus bldg&paved
parking)
I
#of Parking Spaces
Fill: i
volume,&Location)i
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW ® YES
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/or Document#"
B. Does the site contain a brook, body of water or wetlands? NO 0 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: i
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
3
IF YES, describe size, type and location: i
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 0 , NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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°' City of North ampton u .
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f3uilding Department 4
212 Main Street
.1 100
n
Room
2005
orth mpton; MA 01060
phone 413-58 -1240 Fax 413-587-1272
APPLICATION'f0 CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIOR 1,=SITE"INFORMATION
o1.1 Property Address fice
, l/O/ts'rvl. 12.E �/O S Zone 5 Overlay Disncf
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Elm�•SL°D�sfG� �� t CB�istFtct� ,
SECTION 2-PROPERTY.OWNERSHIP/AUTHORIZED AGENT,
2.1 Owner of Record:
11/G�d Z
ei e�.g t/ y �/ �e YA�✓ zoo a =GVrr• ,�; >i�
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: 7 �`
t��r J l s�'A�T,ljC� �� f/�'i'�� � �'-C���' .��jl, /<f� �✓/G�� j
Name(Print) Current Mailing Address:
_/3 .5- ' .9 75_a
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
e9
2. Electrical (b}Estimated Total Cost of
Construction from 6
3. Plumbing Building Pennit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 5U'c?�-� �-� Check Number d'®
This Sectioii'Fdr.Official Use Only
Date,
Building Permit Number Issued:
Signature: ,- 1
i
Building Commissioner/inspector of Buildings Date
971 RYAN RD BP-2005-1194
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 -043 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1194
Project# IS-2005-1615
Est. Cost: $5000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Larry Yentsch 048666
Lot Size(sa. ft.): 19994.04 Owner: CUSTEAU GERARD A&DOROTHY R
Zoning: SR Applicant: Larry Yentsch
AT: 971 RYAN RD
Applicant Address: Phone: Insurance:
P O BOX 120 (413) 584-4750
LEEDSMA01053 ISSUED ON.618105 0:00:00
TO PERFORM THE FOLLOWING WORK:REPAIR TERMITE DAMAGE
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 6/8/05 0:00:00 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo