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DEPARTMENT OF BUILDr1�,?G 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 780CMR 108.3.4 to
act as his/her construction sups:-, 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 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
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 regulations. 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, _� •� understand the above.
(Home owner/resid'ent'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
tnxrTO �
a G,1ill Of �,NLrj-tllziljtpfnli _
6
DEPARTMEN-F 017 LUILDMC INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORICER'S COMTENISATION INSURANCE AAFFMAVI.T
�:rith a principal place of busmnshcsidetice t:do hereby Ccrdfyt La:' 1 tllc• :,pi_ills i?ilci pcil'n-I'Lics of 7Cf�lll�r illi!!
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( ) I am an employer providin, the follo"vmQ ,;oli,crs compcDlsation covcra",c TO, In>>
employees working, on t?lis job:
(1=,L=C.- Company) e c:Number) ---- (F�> ;r don Date)
(l�j�am a sole promicter, 'Tenerai C�:);l12-2c7 c; o- ' on eo�>a�er ! ucle one i and t.ave 11ir t
the contractors listed beiow%-Om the `oll porkers co �ensa orl ;oi .cs:
l U�CCo.f�
),W 1 i✓) .
(,Iamc of( ontnctor) (Ins r acc Cann-:] :Pc! c, Pvtulnfrr) r.,. .+..;o- D�tc)
l a
(Name of CoptT-ac,,Or) -- fln--lr,_nc° Co y rI`iPe!iei Ntnisr) (F:p .aiin Date)
(1\Tamc of Contiaclor) — (1tlslr Ilcc COi ::'_�'i%i�OI;C: t�lIlIlli:I) (_Si,ir:rk,7. Dal',)
- (Name of Contractor) — (II>satat]c--, Com7_ty1Po1i Numt.�r) fF::ri-.tio- Dare)
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l 1 �LIT1 �. U1C 1?IOj)r1f C?i i::l'1 h�?VC t?O Olic .."U? ii]�' toI m—
homc 0�'1IlC„ iiC'riC l?l1n� �1l i?. `r� f- �<� C� 6C��Z� (,✓� 0-1-t-
C�6 l
*10'fF:plcsc lr nt+�:c il:;:•.�1 ilc tx<rco��zr_-3«,o c-pl:-y lr-:--:��;:>.:-��-.:�ncc,cx:.r_r.:�..:�cr:ri�air.c,;:: _ :.�cl!i.�-.
not tnCte th n[hrno uui+�ir.«i dr he k:rz� r T=d: cam-a;L`w .t:,�zr ut crarl Lhc o e 2 n�{cerrsilly
c�tployca u_us t}r tivc:i:r'a cc --: i n/•r (�' _ '
by&horicou•ncsfort Grcx ct p:r:::::•
Icgal etahu of an omployx under tLo workc1e Co,-L-t,nr_.tion AcL
I u--K s=tand ILat a copy of tli><ctatcrs_'nuy bo forwnrclo-;1 to tl»D-Ji tn—d of IrwilrstriJ M v'�t&Off' O of 1::;+.�r�:c for t!m
covcrl&c vailiealioo and that failtuc to:^ coy T�„urd::sc�,iM 25A of MC-L,152 can Ic_d to the rn siiioa cf cry ir_1 p c alt:s
oomiating of a fur_of up to S 1-500.00 ant lcy inrp s x rncn!of::p in rr.-}- r.-.j c vil crultia in �fcmn of ft Sic-,)`;ti's f.Ch�:r-A n
Lrt of 5100.00 a day igain i rrr
F,d i—`L'—tal u—c.ily
f perrnit Numb.:r ------ --
7-7V, -
Si nnturc cif r,'•` ' { --- - --
S�CTON� CONSRUCTIQN SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Ree s e're- -om mprove:rnen Y: on#racfo
RENEW
Not Applicable ❑
Company Name 5>e r Registration Number
Address CJ Expiration Date
Telephone
SECT10N10 WORKERS' COMPENSATIONANSU, NCE=AEFIDAV:IT(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...... ❑
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 15') (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, Statt d Local Zoning Laws and State of Massachusetts General Laws Annotated.
omeowner Signature
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SELT�iO F T4ONiIFPR0 POSEDWORK 6 heck=a1f a I�ca�ble � ;
New House ❑ Addition ❑ Replacement Andows Alteration(s) nr_11,
Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolitionfl New Signs [ ] Decks [ ) Siding[ ) Other [ )
Brief Description of Proposed Work: ricA Q&e-(r7C �c�l�►� �� ( t_>C iS h �( 1c i 1. M�
Alteration of existing bedroom Yes °fN0 Adding new bedroom Yes L----No
Attached Narrative 0 Renovating unfinished basement Yes ✓/No
Plans Attached Roll 0 .Sheet 0
r-oadd.tt on to i fstioghousing�"cotnp.e-e. die fo11MWing_
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? ri
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
�
f. Method of heating? �0- 5Z 12 Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction �'� ��� rc '� ^ r1��� v�f nCj N_,�in C( D > �L,(�
i. Is construction within 100 ft. of wetlands? Yes ZNo. Is construction within 100 yr. floodplain Yes Nc
j. Depth of basement or cellar floor below finished grade /
k. Will building conform to the Building and oning regulations? ✓ Yes No .
I. Septic Tank City Sewer Private well City ater Supply
Y
SECT101�1 1TYL R�U71H) RIZ ATION TO BE COMPLETED WHEN
OWNES1GE CONTRACTOR APPLIES FOR BUILDINGPERMIT
r, .
I. as Owner of the subject property
hereby authorize to ac;. or
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 ins and penalties of perjury.
Print Name /1
Signature of Owner/Agent Date v x'61 V3
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size ' G�c�� SG�•
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage I c O 0 %
Open Space Footage %
(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 DON'T KNOW ✓ YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO V DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO ✓ DON'T KNOW
YES
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 ✓ NO
IF YES, describe size, type and location: V�C-e iechlti
r v tul r
D. Are thhre any proposed changes to or additions of signs intended for the property ?YES
No
IF°YES, describe size, type and location:
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413.587-1240 Fax 413.587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR; RENOVATE AR•-•1 A 1.1-&H-, -0114E OR TWO FAMILY DWELLING
z`
t
1
' I
SECTION 1:-SITE INFORMATION _} �i 3 0 2- l
� �����•� � This e ti°o• to b. o e �"by" ff�ce�' �� ��;
1.1 Property Address:
G /Ltd l �- Zone Oue I Dtstrt- _ ,
SECTION 2-'PROPERTY"OWNERSHIP./AUTHORIZED'AGENT
2.1 Owner of Record: �7 p
Name(P Current Mailing Address:
nam",,t.c-
P17/3-)e1A.10—
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone _
SECTI0N..3:-ESTIMATED CONSTRUCTION COSTS "
Item Estimated Cost (Dollars)to be Official Use°Only
completed by ermit applicant
1. Building I (a) Building Permit Fee
2. Electrical a Q (b) =stimated Total Cost of
Constructionjrom 6
3, Plumbing �06 Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) Check Number O?� Q
This Section For Official Use Only
Building Permit-Number: Date Issued:
" Signature: ''
Building Commissionerllnspector of Buildings Date;
t
File#BP-2004-0528
APPLICANT/CONTACT PERSON PORTER MATTHEW D&CATHERINE B
ADDRESS/PHONE 988 RYAN RD (413)584-5521 O
��'►�z - 1-Soa--'?16--9 9-0,/
PROPERTY LOCATION 988 RYAN RD
MAP 35 PARCEL 044 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid /w., 0,5,0
Typeof Construction: UPDATING BATHROOM
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 FO,LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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 Co ion
An 12,123
Signature of Building Official Dat
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.
388 RYA BP-2004-0528
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category: BUILDING PERMIT
Permit# BP-2004-0528
Project# JS-2004-0745
Est. Cost: $2650.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 25264.80 Owner: PORTER MATTHEW D&CATHERINE B
Zoning: SR Applicant: PORTER MATTHEW D & CATHERINE B
AT. 988 RYAN RD
Applicant Address: Phone: Insurance:
988 RYAN RD (413) 584-5521 O
FLORENCEMA01062 ISSUED ON.1113103 0:00:00
TO PERFORM THE FOLLOWING WORK.-UPDATING BATHROOM
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 Sienature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 11/3/03 0:00:00 2152 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo