35-059 (3) 0 0
;� ► " Cris of Paz#4antp#ntt z
�lASSA[I�ITStttS -
DEPARTMENT OF BUILDING INSPECTIONS �
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060 5 .
y
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction supc-.,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 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 roueh 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
(H '��fi'''"r�.L understand the above.
ome owner/resident's requesting exemption)
signature re
g q g tion P )
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
;, �, C1�zftt z1f Tc7�-ffl�i»r}�fntt �--
� ,. 6 f't�cssxrflnsrtls �` __
Q DEPARTMENT OF EUILDf1�G INSPECTIONS
212 Maui Street ' Municipal Budding
Northampton, Mass. 01060
WORKER'S COMWENSATTON INSURANCE A-FF DAVI-T
i,
----------------------------------
v"Ith a principal place, of business/re:idence
;•StrCcL cirri:;;
do hereby CelLLY UnC'cl dic i) !I1S ailj pcn.,Itic;: o1 pC�lll :Ila-,
( ) I am au employer providing the fo!lo'.vinc `.rorr_crs eornpensat 0II c.overr:1-1,c or my
employees worldrig on t?Iis job:
(I=-L=cZ Ccrnpam') e�-;c;N-am bcr) ---- (E�;rir ti-on Date)
( j I Lm a sole propnetor, om o,.vD r (circle one i and trove hired
the Contractors listed beio,
1 orri s coy: � nsa�on -:o es
(-N=c Of C0IIIL-cLOr} �nS�P;1C LO:P.n::��i�011 �'1]lIl)Cr) '` :,..iC i Datc)
(N=c of C012tl 3C"Or) P.C:, COm D ;iV17c.!!c- Nl rlcrr) (Ex-:�;' t!on Date)
(Name of Coat;actor) rt - -----
ns sZCti Comi ofic. Nur�lr_r) _.z a Daic)
- (Name of Contractor) — (Ias�rarlc Comaiv!PoLcr
.. eii..�._=......-
(
tin a home Ow11Cr i)ciir07Mln„
NOTE plcasc be atrz c tY:at cl!ir.'r:
not tmvc tlL:n Lhrco uni+i in ui ic+t L`�c 6;.-.�rtr. r=.,:z a•o;
Icgzl ctatuc of an�nployx unur n Wcv�cK Cat,m.tion .cL
I ur�de-Yta.nd th t a copy of t}ui ct.t—i. t evy bo fcnw,ve!. J to 11n D-jn tn—i of lr>Lizriel 0-ISoo of i:::..�r ry-a for itx
cove vc Giioo
and Lhat fl durc to c- c CO*-r_M ur.�n-::chic-:2 5A of?.tGl,152 can Ic-d to tlx imposition of c .:.-j per:aL':ca
comisting of a filer_of up to S 1'S00.00 a:r.�.'cY i :;:r, r.z..:!of::p to cr..}t e:-.I civil rsul6cz 3n d4 finn cif a S!c.,`;Jc Y Ch _nd
t of 5l Drj.OIJ a dsy iri_in:.l m.. .
Fcr d, ;—'^r:a1 urc oily i
Pcrinit
-- ---- -- --
!OnaCLIrC c f i.icc:: cdl'rCnt,.f<r: r f
dr
SECTjON 8=CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
r Re i" a.e orne m r uernen .Con raetorM. - -- a Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORK ERS'.COMPENSATION INSURANCE-AFFIDAVIT(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-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 frr 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.
\_)Jomeowner Signature �J/ � �►' �f�-
nrz
SECTION�3DES R1-P-T ON OFcPROPOSED�0'RK(check all applicable) .
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ DemolitionW New Signs [ ] Decks [ ] Sidin [ ) Other [ ]
Brief Description of Proposed Work: ri�D✓ 4N�Cf1c- A2R
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll O- Sheet❑
6a�lfi� o:"�e` °a°nd�or aid'i`tion�wto.exi"stingaiou'sing��cotnp'lefe thewfoflow�n
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 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
SECTIONa zOWNER AUTHORIZATION -,TO BEiCOMPLETED..;blHEN
OWNERSAOENTOR CONTRACTOR APPLIES, FOR BUILDING PERMIT-
I
as Owner of the subject property
hereby authorize to act on
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 pains and penalties of perjury.
Print Name
ignature of Owner/Agent Dag
r
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
I
Lot Size
Frontage f
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking S aces
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 _ DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT 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
FB ing Department s
-� 2 Main Street a
oom 100 dab a
JUN g
1 0 2004No pton, MA 01060 ' ''
h
one 413 587-1240 Fax 413-587-1272 P!
DF-i? P' LD!11u I,NSPE
11-;111M MUM APPLICATI ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This sectron to be completed by office
1.1 Prooedy Address:
pp r
vZ '1 A�✓ loo, � Map ' tot tin
C y 6z�•'✓C Zone Overlay D�stnct
Elm SE.D�strtct CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1'Owner of Record:
6 .
Name(Print) Current Mailing Address:
���e /-5�I�-�✓�z-�C
Telephone
Ln-�S it E3
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
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
2. Electrical (b)Estimated Total Cost of
Construction from:(6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (I +2 + 3 +4+ 5) Check Number
This Section For Official Use Only
Building Permit Number: _ Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-1262
APPLICANT/CONTACT PERSON HUBBARD WILLIAM B&SANDRA S
ADDRESS/PHONE P O BOX 60166 FLORENCE (413) 586-2508 Q
PROPERTY LOCATION 932 RYAN RD
MAP 35 PARCEL 059 001 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 16--
Typeof Construction: DEMO DET GARAGE
New Construction
Non Structural interior renovations
Addition to Existinp-
Accesso1y Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING 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 Co ion
ZOO
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.
-,93Z''RVANA D' BP-2004-1262
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV.-Block:35-059 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-1262
Project# IS-2004-1904
Est. Cost: $0.00
Fee: $15.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 66211.20 Owner: HUBBARD WILLIAM B&SANDRA S
Zoning: SR Applicant HUBBARD WILLIAM B & SANDRA S
AT. 932 RYAN RD
Applicant Address: Phone: Insurance:
P O BOX 60166 (413) 586-2508 ()
FLORENCEMA01062 ISSUED ON:717104 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMO DET GARAGE
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 Occupant r� Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 7/7/04 0:00:00 15 $15.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo