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m DEPARTMENT OF BUILDING INSPECTIONS
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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 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 backfll),
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, C 1 C, ,P— the above.
(Home owner/resident's sigx4dukKrequesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date t �"
Address of work
location T
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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building 'a
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AFMA.VTT
(licenserJpermittee)
with a principal place of business/residence- at:
(phone#)
(stmeVcity/stafd2ip)
do hereby certify, under the pains and penalties of perjury, that:
( ) I am au employer providing the following worker's compensation coverage for my
employees woriang on this job:
(Insurance Company) (Policy Number) (Expiration Date)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Poticy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance- Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(attach additiomr sbc: if noDcnary to include information pertaining to all coaunctors)
( ) I am a sole proprietor and have no one working for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware thst vehilo hcmcowncca who employ pc c;=to do rnxadzaxa mnsrrudion or repair work on a dwelling of
not morn than thruo units in wlvch the homoowncr rtzidcs or on the grounds appurtenant thacto arc no(gmcrally oomtdcrcd to be
employrra under the woriret's.aomp=satioa Act appLka6an by a homoowncr for a license or permit may evidcnoc tho
legal ctxtu of an amp under the Workcez Compemaiion AcL
I understand that a copy of this etatammt may bo forwarded to tho Depa. a of In&ubiar Acci&n&OfEoe of Imurineo for the
coverage vaificadon and that failure to aecttre covemp under stcUoa 25A of MOL 152 can lead to the imposition of aimintil pcmalfics
ooe sting of a rme'of up to S1,500.00 and/or imptisormneri of up to one y=and civil pcnaltia in the form of a Stop Work Order and a
fim of S 100.00 a day tpiwl ttrc.
For dcpa�ufO 4cay
Permit Number
Lot#
gnature of Licensee/Permittee :
SECTION 8=°CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
�N
R =ice re m r vejen n ` F .WR vj _ Not Applicable 11
�.t
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS' 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...... ❑
. ,,.. r ,YYI:
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 Lo g Laws and State of Massachusetts General Laws Annotated.
_J��Hoineowner Signature
r Y
SECTION 5'. DESCRIPTION OF PROPOSED WORK(check all ap lip cable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑ 1
Accessory Bldg. X Demolition❑ New Signs [ ] Decks [ ) Siding[ ] Other [ ]
Brief Description of Proposed Wor �,P, k °
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 if f�e�r holtsWladd e ditiori`1o'ezistirigtiFiousing; corn'ple"teethe following
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
SECTION;7A OWNER=`AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS<AGENT'OR'�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
I, 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.
-1� AF2 AZ
Print INKme
J/0 ev
Signature w er/ nt Date
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 /76
Frontage
Setbacks Front '16
Side L: R: L: R: )O
Rear p?
Building Height
Bldg. Square Footage %
Open Space Footage �. % [ w
(Lot area minus bldg&paved
parking) 111 {
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW K 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 }C 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:
'ty of Northampton
i ilding Department
l' tl r
?
1212 Main Street
Room 100 e
JUN 3 0 2004 t ampton, MA 01060 et O
phone 413 7.1240 Fax 413-587-1272 1,ro-) Site P ti
!Z�wylw UCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address, This section to b�compietetlbyofftce
Y - MaP Lot� �� 11f
Zone O�eriay District
;t
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
A-Tan--
Na e(Print C4 rent Mailing Addr s
4�rr — qVq
T'ele one
On
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
c m feted by ermit applicant
1. Building J!_00 (a) Building Permit Fee
2. Electrical V (b) Estimated Total Cost of
N4 Construction from 6
3. Plumbing 4 Building;'Permit Fee
4. Mechanical (HVAC) VA
5. Fire Protection V7 i
6. Total = (1 + 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-2004-1346
APPLICANT/CONTACT PERSON YOUNGER-FLYNN JOY&PETER
ADDRESS/PHONE 848 RYAN RD FLORENCE Q 586-9443 Q
PROPERTY LOCATION 848 RYAN RD
MAP 35 PARCEL 076 001 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
Tvneof Construction: ERECTI2 X 16 SHED
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF(1MATION 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 Stre 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.
r
848 RYAN RD BP-2004-1346
GIs#: COMMONWEALTH OF MASSACHUSETTS
MgR:Block:35-076 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate or : BUILDING PERMIT
Permit# BP-2004-1346
Proiect# JS-2004-2022
Est.Cost: $500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 17554.68 Owner: YOUNGER-FLYNN JOY&PETER
Zoning:SR Applicant: YOUNGER-FLYNN JOY & PETER
AT. 848 RYAN RD
Applicant Address: Phone: Insurance:
848 RYAN RD O 586-9443 O
FLORENCEMA01062 ISSUED ON.712104 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECTI2 X 16 SHED
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• Receipt No: Date Paid: Check No: Amount:
Building 7/2/04 0:00:00 285 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo