35-056 ¢'CtSAA1P�.
Crify of Northampton z
$ � �assacliuseiis
DEPARTMENT OF BUILDI71G 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 sup(:: .,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 famt
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 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 your), 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/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
i
j
o4�lw•rn�0 -
tiE GltL3 of MICIrtl}aiitplolt
i ;as a achnsrtIa'
o DEPT RTMEI-T OP BUILDf]\'C INSPECTIOI.'S
I _
212 Main Strcct _h-funicipal DwId;ng
j ?Northampton, Mass. 01060
WOR CER'S C0KPENSA'n0N MSURA-NCE AFFMA.ArIl
(i;ccvsx/perm,tttx)
%IrlLh a plzncip lace of business/residence at: - --
(phone-!)
� (sar...t1c�t-r/sZatL�a p)
do hereby ccrdf;, under thc.pauis and penalties of pc 'ury, -:h2i
( an employer providing the following worker's comDUISZzion cove—c for Iny
j emplovecs worloag on this job:
r
Clnst>r-� Conn: ) (Policy Nt=b-cr) _ (r:pirtior, Day.) "
( ) I am a sole proprietor, general contractor or homeowner (cZ c:e one) and have hired
the contractors listed below rrbo have the folio%vino worker's camnen_c.26on paiicies:
('NQnl: Of Co !^Ci0") (IRRlrat1cc COIDoanyil GUci NIUn1RCr) (t_\JIF'J"lon Datc)
I
(N ame of Coomaor) (11nsuranc-, ComoanviPoUm, \uminr) (Expirzt;on Date)
I
I
I
(Name of Coarmcio:) (I.nsuranc; ComPacyfl?aucy Numb,-:) (Expirdoo Datc)
(Name of COt111aCtOr
(Insura.a(-- Comcazy/Policy Numbs) (Expirdlioa Darr).
(aaa�_du�oc�.t s'�cC.if ncoa.�•
to atciaform,�oa perta.iain.s a.1J cwr_.cva) -
I ( am a sore proprietor and have no one wof-Ling for me.
( ) I am..a home owner performing all the work myself.
NOTE:ple be ewuc ttL,".-1 to b0c-c%�mer3—bo c=play peso=to d3 -mil-,• =--=joa c rcp=work on of
ant mete the[zx L-ti a in u'zi�ttx bomo -ocr side:oc oe the pwact,z,-•puttcu:.r1 b c oo C .t cce d od m be
citployc s uncle 6-Nai:d�-0=cpc---+•oe Act(GL!152-=1(5))�:4*U=L600 by a bommave fez a lice_or permit=y c%idco=the
legsl cU u<of as-= loyar uodar d.Wo'+a 'C-a*-=aL;on AcL
1 aindczi,nd d"'a'PY of tLu mc=mc l m.Y to the Dip a N.6-1 A a&c 'OfL—of tmunoa+for Ih.
covc�c vc'JGoiioa and that L-3J=c to soaut:tovR�undc r soctioa 2.5 A of).(OL 152 aw I=d to the i pcal6oa of Qimimal P=AI lc
eo—i:-! g of a fine of up to s 1 500.00 and/or oCup to one y=LDd cavil pcaxJum in 6c fo=of a Stop Wor'k Otsier and
fish 0(5100.00 d_Y a
me
For dgs.+ta,---sl u.e only
L/ 1.dap: Lot
I tun of LiomscclPcrmiucc e J
SECTION 8-CONSTRUCTION SERVICES 71
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9Rea €ecltivrnemcireuier €anta µ s Not Applicable ❑
Company Name Registration um er ---
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(N1:G:L.c:152.=tgs,ct6))
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...... ❑
.wu �1F1� srete i�
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 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 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
r
SECTION<5-DESCRIPTION OF PROPOSED WORK(check-alt`ayolicabte)
New House Addition ❑ Replacement Windows Alteration(s) Roofing /ter
Or Doors E3
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[E3] Other[�]
Brief Description of Proposed
/?
Work:
. -. f _
Alteration of existing bedroom s No Adding new bedr o Yes No .
Attached Narrative Renovating unfnish asement Yes No
Plans Attached Roll -Sheet
a Nev Y o se rt ` ' cf>tra o exrs �crc1 'c Stacriec E a:
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?a-,OWNER`AUTHORIZATION TO BE COMOLETED-"WHttt,
OWNERS-AGENT°OREONTRAETOR:APPLIES FOR b0iLDI4GiPERMIT
I,
as Owner of the subject
property
hereby authorize
to act on my behalf,in all atters relative to wor nzed by this building permit application. ----
Signature of °wner Date
------
as Owner/Authorized
Agent hereby decl a that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under thins and penalties of perj
Print Name
natu of Owner/A ent Date
'
--
Section 4. ZONING All Informatibri 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 r77=
Bldg. Square Footage 011'0 F-1
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has u| Perm it/Varance/Findi ever been bsuadfor/on the s�e?
N"' 0 DON7RNOVV 0 YES 0 �
IF YES, date bsue
IF YES: Was the permit recorded at the Registry of Deeds?
NO K � DON7 VV K�O YES��
IF YES: enter 8noh i Page': and/or Documnent#
�� ��
B. Does the site contain a brook, body of water orwetlands? NO �~��� DON'T KNOW �_� YES �~�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
'
Needs tmbaobtained v���~� Obtained �~v��� Date'
C. Do any signs exist unthe 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 0 NO 0
IF YES, describe size, type and location:
E Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre orisd part nfo common plan
that will disturb over 1acre? YEGK-��) NO K )
! `�/
|F YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Nortoampton
Building Department
212 Main Street
Room 100
Northampton;MA 01060 ,
phone 413-587-1240 Fax 413-587-1272 -
e `�
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIONA.=SITE'INFORMATION
" Thtssecttactto be completedGbyaff[ee
1.1 Proaerty Address:
" d
Overlay E istrrcf
'/ v / 'Y Grr�. Cii��g4f[f:46 �`,c S � r I> `•� '+l V�Q13{Fb< k : ,.'..Y
SECTION 2—PROPERTYOWNERSNIP/AUTHORIZED AGENT, _
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Anent:
Name(Pn Current Mailing Address:
�r
Signatur Telephone
SECT N'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.Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) CheckNumber
This'Sectiori For OfficiaC Use.Onl
"".Date
-
Building Permit Number. issued:
Signature: r
Building-Commissioner/Inspector of Buildings Date
944 RYAN RD BP-2005-1135
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 -056 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildinci
Category: BUILDING PERMIT
Permit# BP-2005-1135
Project# IS-2005-1534
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: James Roberts 117154
Lot Size(ss . ft.): 15376.68 Owner: SCOTT MAURICE E&DONNA M
Zoning: SR Applicant: James Roberts
AT. 944 RYAN RD
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON.5 113105 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF
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 Occupangy si nature:
FeeType• Date Paid: Amount:
Building 5/13/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo