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m DEPARTMENT OF BUILDING INSPECTIONS
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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 super: 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 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.
( ome owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date L 2 2F
Address of work
location
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m DEP/u-tTMENrT Of' DUILDD) G INSPECTIONS
212 Alain Street ' Municipal i3uilcling
INIOrthamptou, Mass. 01060
WORKER'S COMPENSATION INSURANCE A�FFMAYIT
1,
___--
NvIth a principal place of busIIJessJresiCenc_ n..
- --- ----- --------------
(�11c'r1c ")
-------- ------------
do hereby CCr�1I}', LI)C c1- Ll]C' ti 1i1S i.iil7 pCil li1'�S Oi pCt�llrl', i11i!' -
O I am an ernpioyer providing the ;ollo.v;nt •vorr:crs COII1penS I1Cn coverage FOr I11y
e111ployceS worErig on this job:
(Las, ana C mpany) olio,Ntu tber) ----- (F:riratien Date)
( ) I am a sole proprietor, c hor:eQ�•�ner L,cle one) and' '-'a�."e h red
the Contractors listed beiov., ;'h0 }lam `11.
Orri S CrJ�: I7 70i1 "C: S:
'Name of('Orltraclor) (TI1S nC l CI^^;:;it;�G!1C{ Nunbcr) T?'`:rit7Gi: Datc)
(Name of ContT?ezo-) Co-mr),--Iv/?c.!ie; Number) (Exp raiioa Date)
(ir'amc of Contractor) (Ins1 once Co r;a yi'olic: Numir r) x;.'.rmdor lute)
- (Name of Contnctcr) — (IIISZ rar1G Comb y!Po1icy Numl;2s) c).7-, Date)
i
t ) I iun a ole propriet,)r i1;1d have no for(44-- 8111 2'_ homC
NOTE.:p(eru Le a5,a e Les:'.5i'a1e tK!;CUll2Y S 5,rJ Cx.;! y;T.- C V
not uxcc Ih--n throo units in Nv ic11 he k:; >;:5-rte rc_::;=or a; Ecrsall';
ca1Ployc-3 u_rcr; thr 5wri:r cc s :atica A_c:(GL,152-::s!(5)1,rl:•':r..:ir_::by hom-o,5-lcr for a Gccrc cc t,r:,is
Icgal Rater;of nz]cz:plo}'x under t`•�WorJccli io."]�±or_-.r<tian!.cL
I uxsde:tnnd the a copy of this ctatc:s•r_uy bo Iawn ial to tI»I)-tn tZUSaI of,,i.1ALs:�C;I o0 of!:1rr�n for tix
oovczsc vcriS=Iioa and that U- rc to:-v.uc cvv-"-r-and:uC.i v 25A of?,f GL.152 can Ic_d to tiro impasition olcr i. 1 pcx 11;:cs
comisting of a fur-of up to S 1"5C' oo nit 'nr i ilr yr c:1 OF::7 to cr.- e:-.J evil pcm)6cz in do fcnll of+Str., V ri.0u-.:-aid n
f:rte of S l OG.00 <da I.r_ina m:.
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SECON 8 CONS?RUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Reg s Q e rn o ovement o'ntracto L4 Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTI,ON10WORKERS' COMPENSATION 1NSl)RANCE.AFFIDAVIT(M:G:L.,c. 1°52, § 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-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acecptable to the Building Official,that he/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 :eference 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"cert'fiAq and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, St and cal oniyt Lai and Sta e of Massachusetts General Laws Annotated.
Homeowner Signature
a '
}EC7 to] S 001.1 ROPOSfD�IIORK check a l I�ia'ble
,
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ )
Brief Description of Proposed Work: Ytc Lt cc e!"�A —Ej2 til
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 •Sheet 0
a :. t� = ora. d�3tion to ex°rstingh >lo sing comp.E e 7iefolowlnfr
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. Mascheck 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 Nc
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
SEA"". UJORIZATJON TO BE COMPLETED WHEN
0)INN fS E 4 OIITRACTOR APP,I: E FOR BUILDING PERMIT
as Owner of the subject property
hereby author' e to ac; or
my aIf, all m ers ative t work authorized 1'w by this Building permit application.
rgnature 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
Signat a of Owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This eolumn to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
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 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:
D. Are there 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
2 Main Street
Room 100
i �ti�� l� U v h pton, MA 01060
1 M
phone 413 1240 Fax 413-587-1272
APPLICATION TO aQUS4RUCA, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
DES Of ION MA 01060
SECTION 1 -SITE INFORMATION
a r This o om ettedKK:y fic
1.1 Pr pertyAddress:
ull,
SECTION-2 - PROPERfiY=OWNERSHIP./AUTHORIZED`AGENT
2.1 Ow,ne`r of Record: ?
Name(Print) CurrhoE Mail Address:
P- 16l0
Telephone 1 c,
q(3
Signature '
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 -!ESTIMATED CONSTRUCTION CO 5TS
Item Estimated Cost (Dollars) to be Official UseOrily
completed by ermit applicant
1. Building �006 v (a) Building Permit Fee
2. Electrical (b) Estimated Total:Cost of
Construction:fro;m 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check dumber
This Section for Official Use Onl -
Buildng Permit Number: Date Issued:
S►gnature:
Building:Commissioner/Inspector of Buildings Date
File#BP-2004-0145
APPLICANT/CONTACT PERSON BROOKS MICHAEL D&MARILYN L
ADDRESS/PHONE 957 RYAN RD
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
Buildina Permit Filled out
Fee Paid —
f
Tvneof Construction:_FINISH BASEMENT
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 OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 S Commission
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.
x4 BP-2004-0145
o GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0145
Project# IS-2004-0224
Est.Cost: $3000.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group. Homeowner as Contractor
Lot Size(sa.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 O
FLORENCEMA01062 ISSUED ON.8114103 0:00:00
TO PERFORM THE FOLLOWING WORK:FINISH BASEMENT
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• Receipt No: Date Paid: Check No: Amount:
Building 8/14/03 0:00:00 119 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo