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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 hds/her construction super ,,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 fanu1
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 0gulations. 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 is signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 1 3A
Address of work
location cj
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DEPARTMENT OP DUILDfNC INSPECTION'S
212 Main Strcct Municipal Building
Northampton, Mass. 01060
WolUCEIZ'S COIATENSA-ETON MSURANCE Al=1 /i.VIT
i
(]i ccnsxJperm�ttce)
���itl� a principal place of businessfresidence at: - —
_(phone-!)
(so-�.t/ci rJ/stalcl zj p)
do hereby certify, under ttic.pa.in.s and penalties of pellury, hat
( ) I = an employer providing the following iworker's eomocnsabon Coverage for Iny
eii3plovecs woridng on this job:
(Insumn ConrL--�) (Polio-:N' r) -- (T:piratior, D2j--)
1 "
( ) I am a sole proonecor, general contractor or homeowner (ci c:e one) and hz - hired
the coniTactors lister+ below vgbo iLave. the `olloV4u�g worker's comptasailon policies
(i amc Oi Con.Mcio') (1r1R1ralicc C0I1103'1).illobc- NUIIl=< )
I
- (Name of COOD-2clor) (Ins-w ancz COMDan-'-P01C1' Nus;16_r) Date)
(Name of Conuaclor) Onsur nc; Company/PoUcy N:uebcr) (Expiraen Date)
i
(Igtamc of Contractor) (Insurance Comrzay/Pobcy Number) (Expiration Date) .
(aII1Gh z.dit�OC21 t�JCGf,tr n.CC --Y to m,tu<5z�infor=' =oo Pc1La.iasSls to at[
{ ) I am a sole proprietor and have no one working for me-
I am,a home owner performing all the Nvork myself.
NO L.rtC-3C 1X La27C Lt:Y C bCDY.CKLCT]H'bp GS3SpI0y 'QIIl LO(IJ[^�raft- rtrr ��.LJAO C repair work o3 l d%—lt-t,of
oot meet the ' _=rj in u$ieh the bomoa-v r=da or ca the prow zapurtca tbeen we�h .lty oecsid ed to be
c:av1oycs um'-'--dx..air a rtioa A=(GU4 52y 1(5)},apptit 6cm by a bomooQac fcr c bcs=a perm+t n_y cvrd—Lbc
Ivs-t cL�ttu or a.a e=zployer udder dro wockoel Compomat Act
i [undc�aad cha s Dopy of thin cnt.cmnct m..y be for�.ud.sd to th.Dopwtmcaa of Ind..�tricl Aced ntd Offo.of lra+r.00e for th.
covcise rain enioa a_•td that f..itt=to savtt tovrn se uodc socsioa 25 A of MOL 152 nn I=d to the i2rptss2ioa of=in i Pea W-
eoozis of a tine orup to S I}00.00 aitdror of up to ooe)m and aNil pmzlt cm in 6c form of a S�tap wotti��°�' _
riaa o(S 100.00 1 a_y tptima me
i _ r For&�u,e only
PCTri),)t rttSIDt.?CS
j-sL..aG,/ -mil��6 �t
Signauuc or Li cra i cc j !
SECTION'8-CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
teg re me A cx� +a on' Not Applicable ❑
Company Name Registration Num er ---
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE'AFFiDAVIT„(M:G;L.c.152,,-§;23C(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...... ❑
..y 1W MM IY
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-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/she 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 Z ning Laws and tate of Massachusetts General Laws Annotated.
Homeowner Signature
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SECTION 5 DESCRIPTION OF-PROPOSED WORK(check all applicable)
New House ❑ Addition ❑- Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0211, Siding[0] Other[�]
Brief Description of Proposed
Work: LCD r c.. c OAT c t WV�
Alteration of existing bedroom Yes / No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
-�-..� � � a--'-".f ���"K�Ts:rr
sa 1€�kev� -& a:nd >t axfdi#�o►a#o exlsfiri+ io smar-cOr�"pie#e=fhe (ov � ra:
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 Ta-OWNE,RAUTHORIZAT!ON TIO BECOMPLETED.WHEN ,
OWNERS AGENT,OR-CONTRAGTOI2 APPLIES,FOR(BU I LDING.P ERM IT
c
as Owner of the subject
property
hereby authorize
to act n my be f,in all ma rs relative tMork authorized by this building p ap lica
S' nature of Own Da
as Owner/Authorized
Agent hereb d cl re that statements and informatio n the foregoing ap lication are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties oof perjury. '
IJt�
Print Name _
Date
Signature of Owner/Age
Section 4. ZONING All Informatibtt 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 9A x flml^
Frontage
pp'
Setbacks Front
i k 1271 t
Side L: -J R: R
# -,� L:' x I
Rear `-
Building Height ---
Bldg.Square Footage - —( % �
Open Space Footage
(Lot area minus bldg&paved /0
parking)
#of Parking Spaces
Fill: s
i
(volume,&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 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 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 mv
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 tZS
IF YES, describe size, type and location: f
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 Ank
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northam
pton "
Building Department
212 Main Street
Room 100
Northampton; MA 01060
phone 413-587-1240 Fax 413-5�87-1--272
APPLICATION TO CONSTRUCT,ALTER,REPAI% ENOVATE OR DEMOLISH A E OR TWO FAMILY DWELLING
1 3 2005
'SECTION 1.-SITE.INFORMATION t s
1.1 Property Address: This s iott t be completed by office
c1 �7Cl nF � ru UnfS
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_)V-V\ 'C)t � ZoAe Overfa-Uis nct
�EIcq�S>~Distncf � < ."< �• -v��� CBDtstFlCf '" s-,.' ' .
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
N e(Print) Cu ent Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
ua��vin
Name(Print) Current ing Address
Signature Telephone
SECTION 3-ESTIMATED'CONSTRUCTION COSTS
Item . Estimated Cost(Dollars)to be Official Use Only
com leted 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)
5. Fire Protection
6. Total=0 +2+3+4+5) Tt Check Number
This"Section for Official Use Only
Date,
Building Permit Number Issued:
Signature: r
i
Building Commissioner/Inspector of Buildings Date
File#BP-2005-1248
APPLICANT/CONTACT PERSON BROOKS MICHAEL D&MARILYN L
ADDRESS/PHONE 957 RYAN RD FLORENCE (413)584-0599 Q
PROPERTY LOCATION 957 RYAN RD
MAP 35 PARCEL 054 001 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
Typeof Construction: CONSTR CT 5 X 5 DECK OVER STEPS&5 X 15 DECK
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 LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 C ssion
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.
957 RYAN RD BP-2005-1248
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV:Block: 35-054 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1248
Project# JS-2005-1665
Est.Cost: $1000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 19863.36 Owner. BROOKS MICHAEL D&MARILYN L
zoning: SR Applicant: BROOKS MICHAEL D & MARILYN L
AT. 957 RYAN RD
Applicant Address: Phone: Insurance:
957 RYAN RD (413) 584-0599 (�
FLORENCEMA01062 ISSUED ON.6122105 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 5 X 5 DECK OVER STEPS & 5 X 15
DECK
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: Date Paid: Amount:
Building 6/22/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo