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4 DEPARTMENT OP aUtLDf7�G INSPECTIONS
212 Main Strcet . Municipal BuildinE
Northampton, Macs. OIOGO
COI�'TENSA-170N MSCI C- AFMAVIT
I
0;,ccusx/permj(icc)
%frith a pi-Licipal place of buSIncSS/reSidencc zt:
O;none'}
(soc---t/ci ty/slalcln p)
do hereby certify, under the paui is and penalties of pcq'ury-, hal
( ) I a-m an employer providing the followlmz a•orkcl's cornncns-Uon cove mac for my
Clnp(ovccs ��orllg on tilis job
Conn::.nv) lPetir;?-u-mir_r) -- (t xpij-, on Da�)
( } I am z sole proprietor, ge-aeral contractor or homeowner (ci cie one) and have hired
the CoaTactors liste—d below crbo have the following worker's coLpenszoon pciicle.s:
('Nam- of Co:a^cio.r) (ln2ramw Comoyny/Pobc-
(Name of Coacraaor) (lrlstl znc awDa;2-v/?O!1Ci \winder) u-,.uou D:re)
(Name o[Conlraclor) (I-nsurancc Compan)•fpobe)'Numb l) (Exair000 Datc)
I
(Nzmc of Contractor) (Lasu=ca Compzlry/Pobcy Numb rl tSxp m&a Da>c)
(aaa,C�sdaa�ccaJ cS�r_t if ncecs.,;y to i:KU�irzforaa�oo rn-tr-inin6 to.li ooa�-�o:-�) - i
O I am a sole proprietor and have no one worb.og for me.
( ) l am,a home owner perforrrung all the work myself
NOTE:plc be c-ur U+'v,{�lc bcv men wbo employ P,=o m di ..�ca�.:r�on c rc-ziu-m
WC mode th_a ` tmro is\.'bleb the bvm—Dc-residue or oo the gr LC 1,a ppurua:rl U-e, we G- --ay«crdac i to t-
employcz uaCe the Aa(GLI52-=1(5)).=-w4cuion by n boaim—fer a bey_o pare-y dcrn h
IcP.l CLI-of c.a esPtoy. =&d d> W-ic c Coat/s.1;on
i uvdcmapd d-a ooyy of tbi.-ba u m.y bo f---,Id to tbo Do,- mt of Lr& id A-dmt(Om-of 4a—I--
oovart v'T%Gc=oa a'd au L-.il to ubd�atop 23A of MOL 132 ma lct6 to U)c imprxaiod of mmiail pcoalb-
r"mixmg of t fiat of tR to s 1.500.00 and!«iar{risornzr„�of up to a,x yert txl 61il pmal-,io in t`,form of a Stop Wort;Order and
fim of S 100.00 i d-y t{xina oat
F«d�.nrx.=a1 u.c only
Pcral t Number
Sigmatum of LicatscrlPcrm3UCC
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DEPARTMENT OF BUILDING INSPEC'T'IONS
INSPECTOR 212 Main Street • Mmicipal Building 'a�4 S
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 1083.4 to
act as iris/her construction sup,.: .;Sor. -lie 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)s
sonotube holes before our a rough buildin 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 koklq
Address of work n r
location �7`►� {,[,Ll
(-(a.4�AX AeJ7 o�o(Q 2-
g - deO : TO 00 fiT 100
SECTION 8-CONSTRUCTION SERVICES J1.
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
„ r Not Applicable
Seats€eredEElanmpravdri�ertact* L, S v� PP
Company Name Registration_Number --
Address Expiration Date
Telephone
SECTION 10=WORKERS'COIiAPENSATION'INSURANCE AFFIDAVIT-(M.GL.c 1`82,.§: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 bulldog permit.
Signed Affidavit Attached Yes....... No...... ❑
s , warlerll>rio
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 sball 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 oning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
r
�n q -E,t
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition F-] ReWacement Wjradows Alteration(s) Roofing
oors
Accessory Bldg. Demolition n New Signs [O] Decks [Q Siding[ Other[tom]
Brief Qescripfion of Pro osed
Wor � t
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes �No
Plans Attached Roll -Sheet
Ca.If New house.and:'::a`r additioW6o-' isti rc houslt� o, mple _ foI1owiRk
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 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
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 Ithe pains aino penalties of per'ury.
Print Name
I
Signature of Owner/ nt Date
O .d dLQ : TO Q0 +-T 130
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Deparrment
. .............
Lot Size F
Frontage
Setbacks Front
Side L: R: L1 R .............i
Rear
Building Height ------
Bldg.Square Footage %
'c Footage
Open Space Footage %
us &
(Lot area minus Square
&paved
parking)
...........
9 of Parking Spaces
Fill: ..........
(volume&Location) ..........
A. Has a Special Perm it/Variance/F ind ingever been issued for/on the site? how
A—/
NO 0 DON'T KNOW YES 0
: - - "--- I
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
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:
0 0 1
C. Do any signs exist on the property? YES NO AIN
0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,qxc vation,or filling)over I acre or is it part of a common plan
that will disturb over I acre? YES 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
2 -CI clLQ : TO 90 4-T "DO
3
City of(Northampton � �� erne � C�
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t Building Department e eSs�t
212 Main Street Afrabtttt
M ,
Room 100 11 b ltt� x
- Northampton, MA 01060 wo ofS turn E n ,
"'phone 413-587-1240 Fax 413-587-1272 RtlS ` Carr r 5 �
ICONS JTUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
_SECTION 1 -SITE INFORMATION
1.1 Property Address: This-section to>be completed by office
Map Lot Unit
pl cx A� 0t06� Zone Overlay District
Ern St:ois,fief t '.. - CS District_.-.
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�tl&A Gat'ra*L"4 ►
Name(Print) lent Mai g`1re
Telephone R
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 Ob (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=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number: Date
Issued:
Signature:
w ing ommissi tot of Buildings Date
/j
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1357 BURTS PIT RD BP-2006-0418
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35- 170 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0418
Project# JS-2006-0608
Est. Cost: $500.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 30056.40 Owner: LAWTON JENNIFER GARRATT
Zoning: SR Applicant. LAWTON JENNIFER GARRATT
AT. 1357 BURTS PIT RD
Applicant Address: Phone: Insurance:
1357 BURTS PIT RD (413) 586-1761 ()
FLORENCEMA01062 ISSUED ON.1011712005 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL GARAGE DOOR & CEDAR SHINGLES
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 Si nature:
FeeType: Date Paid: Amount:
Building 10/17/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo