35-206 (6) gT1�1P�.
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DEPARTMENT OF BUILDING 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 supc.•,' °:or. 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 0gulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfft
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 s the proper permits and inspections are
made _
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 c
location
o�tiw-rnTO r..
?1 c3 latch rtsclla' - —"
o DEPARTMEI-I. OP BUILDf?."c INSPPCT101.'S -
j 212 Main Strcct ' Nfunicipal Building
Northampton, Mass. OIOGO
WORICCR'S COI"fQ')✓NSA'nON ONSURANCE AI IMAM-I'
i
t
I
(Ii ccns.x/permj ttCC)
V.rith a pnrtcipal place of business/residence at: --- -
I
(phone=)
i (s[r�.t/ci ty/sralcra p)
do hereby certify, under dic.pauis and penalties of Pc9ury, _h:l
O I am an employer providing the followint,iworkes comncas do, covemge for lny
i
emplvyces Nvortang on Otis job:
I
iazswanc COMS=v) (Pcbc-.Ntimocr) -- (T=:-pir.:tion Da1^.)
O I am a sole proprietor, general contractor or homeowner(c tie one) and have hired
the coli raCtors listed below who have the following workers comoen_"aaon policies
I
i
(l+flrDC Oi Co l^CiOr) (In-umlicc CoIADa ).01 o6q Nf=*_'-_) (Y\)11d 30n l�1LC)
(Name of Conncior) (Insurance COmDaa}vPotic; Numcrr) (—txDU' Lion Date)
i
i
('Name of Conraeio,) (tnsuranc; Compan}'/Poky' Numb j) (Exairdoa Date)
(Name of Cooaaaor) (Insuran(mm Comrzuy/Policy Number) (Expirtian Date).
(LQ,ae�.t zjd&t:'ocil beC,ifacca--y to incv'dc iaformszioa perta,ni:ig to.11 wrr-tn:a)
{ ) I am a sore proprietor and have no one worldDg for me.
I atn..a home owner performing all the work myself.
NOTE:pl=.=be LWjrc tb,- -tata bomco,acra -bo flay p(=raay Lo tU = r rgau 4-0ric oa c tl%% �-Z of
ant mete the a t'.ao L-a?.+is K$iCh the bomoow.c rsad,or oa the p-ouncs zpp�ulcn tbe_ n Li oa c- -,Uy,oecsd-vi to be
rarploycs unc'e the 4Ak=�-C..,,-.-- t=A=(GUI 5 L=1(5)y,=qpUc2_6t a by L bomco a.far=lice__a pa-ma m=y--id—tt:e
lcgsl—of La e-gloyx trader tlw Woaic.a(a Cooap. aiioa Act
I uode*ssad tha a-OVY of tbi.mt.cmcm say be foco.nrd.d to tbo r}cpartmcat of Io�euiel AccdmL•!OQi-of to-.—for th.
oovor xFC�'eiCelioa and ai=i LLI=-c to io==)eovcra uodC wctioa 23A of h(GL 152 m lad to the Ltnpmitioa of airmail peaatlia
o0otititag of a GX orup to S 1.300.00 LnNOC orup to otx y=Lad a%i1 pm.tio is dS form or.Stop Woric Order Lad L
run of S 100. 0 psi me � ------
For dcL,=__�J v.c onJy
PCrmJt)`tlltnt)C1
P."
Si oft ccmiucc Late
SECTION 8-CONSTRUCTION;SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
S e
Is re rep ntri �enr c oirfra r
Not Applicable D
Company Name Registration Rum a-6 -----�--
Address Expiration Date
Telephone
SECTION 10-WORKERS"tdMPENSATldti NSORANCE AFF1DAVf (M.G:L c.152 "25C&jj
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...... ❑
•g�'�
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 responsibb ' for compli ce with the State Building Code,City of
Northampton Ordinances,State ano Loca Zoning Laws an to of Mass etts General Laws Annotated.
Homeowner Signature
f
i
SECTION S-DESCRIPTION OF PROPOSED WORK(check,all applicable}
New House ❑ Addition ❑:: Replacement Windows Alterations) ❑ Roofing ❑
Or Doors Cl
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding(W] Other[C7
Brief Description of Proposed
Work: G v�J S
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a tt vv a se i�cf a 18406 x R-0ff" ar�stl c:.,+cor pte t� [ urcEn t:
a. Use of building:One Family Two Family Other
b. Number of rooms in each family u it: Number of Bathrooms
c. Is there a garage attached? l v y
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 ComplianW. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes y No. Is construction within 100 Y r. flood lain Yes No
p
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and'/Loning regulations? Yes No.
I. Septic Tank City Sewer ✓ Private well City water Supply
SECTION Ta-OWNER AUT90R.IZATfON-T6 BE-C,OMOLE-T-ED,-,WHEW
OWNERS AGENT,OR CONTRACTOR APPLIES FOR'BpILDINGPERMIT
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 Mthe foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name '
Signature of Owner/Agent /' Date
Section 4. ZONING All Informatioh 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 I i
Frontage I j
Setbacks Front i
Side L+ I R:' L: R:a
Rear
Building Height
Bldg.Square Footage � % -�
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill: r I
volume,&Location)
A. Has a Special Permit/Variance/Finding eder been issued for/on the site?
NO 0 DONT KNOW YES 0
I
IF YES, date issued:;
IF YES: Was the permit recorded at the Regi y of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book Page# nd/or Document# 1
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q Date Issu
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location: j E
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO QUA
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 , NO -.
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
e
City of Nortoampton
Building Department
212 Main Street
Room 100 e
Northampton; MA 01060
phone 413-587-1240 Fax 413-587-1272 t?t
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION,1 -SI.TE7NFORMATION '
1.1 Property Address:
This section Labe comeletedby'o�ce
� t
w
l
1 1i i j
�01 �oi E3uerfa District x
.06 A, WD
SECTION'2-PROPERTY'OWNERSHIPIAUTHORIZED AGENT.
2.1 Owner of Record:
i
J (_f e
Name(Print) Current Mailing Address:
Telephone '-2. C'
Signature
2.2 Authori e A ent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION ZOStS,
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=(1 +2+3+4+5) iC heck Number
This Sectlo�l=o`r'OfhcIal`Us'e Only
Building Permit Number. I'ssued
Signature: r
i
Building Commissioner/Inspector of Buildings Date
BP-2005-0998
GI
S#:#. COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0998
Project# JS-2005-1377
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.): 67082.40 Owner: LAVALLEE JASON A&
Zoning: SR Applicant: LAVALLEE JASON A &
AT. 1244 BURTS PIT RD
Applicant Address: Phone: Insurance:
1244 BURTS PIT RD 0303-9110 (�
FLORENCEMA01062 ISSUED ON:4 115 105 0.00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL SIDING
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: Date Paid: Amount:
Building 4/15/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
VIII. ZONING PLAN EXAMINERS NOTES
DISTRICT
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
IX. SITE OR PLOT PLAN — For Applicant Use
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BOCA FORM APEBP — 669 01969 BUILDING OFFICIALS & CODE ADMINISTRATORS INTERNATIONAL, INC.
IV. IDENTIFICATION — To be completed by all applicants
Name Mailing address — (dumber, street, city, and State ZIP code Tel.
�No.
Owner or j7o 7 -) Gj ` - . /. S ✓ J J
Lessee
Builder's
) License No.
Contractor
37
3. f
O
Architect or s G S 7
Engineer
I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to
make this application as his authorized agent and we agree to conform to all applicable laws of this jurisdiction.
Signature of applicant Address Application date
Ar
S i
DO NOT WRITE BELOW THIS LINE
V. PLAN REVIEW RECORD — For office use
Plans Review Re uired Check Plan Review Date Plans B Date Plans B Notes
9 Fee Started y Approved y
BUILDING
PLUMBING
MECHANICAL
ELECTRICAL
OTHER
VI. ADDITIONAL PERMITS REQUIRED OR OTHER JURISDICTION APPROVALS
Permit or A rovaI Check Date Number B Permit or Approval Check Date Number B
pp Obtained y pp Obtained By
BOILER PLUMBING
CURB OR SIDEWALK CUT ROOFING
ELEVATOR SEWER
ELECTRICAL SIGN OR BILLBOARD
FURNACE STREET GRADES
GRADING USE OF PUBLIC AREAS
OIL BURNER WRECKING
OTHER OTHER
VII. VALIDATION
Building FOR DEPARTMENT USE ONLY
Permit number
Building Use Group
Permit issued 19
Building --�--
Fire Grading
/�" �
Permit Fee $ C� Live Loading
Occupancy Load
Certificate of Occupancy
A d by:
Drain Tile
+ i
Plan Review Fee
T I T LIE
i
r s
I hereby certify that the"proposed'work is authorized by the owner of record ,
and I have been authorized by the ow er to make this application as his
authorized agent.
M1
SIGNATURE OF AGENT
ADDRESS
(NUMBER) (STRE T) •_ , (CITY) _
APPROVED BY TITLE
r
DATE 19
c
I
I
DEPARTMENT OF BUILDING INSPECTIONS F DEPT. PILE COPY
212 MAIN STREET Z o
NORTHAMPToN, MA, m6o BUILDING a a
35 — 206 CODE # 79 PERMIT VALIDATION
DATE November 14, 19 79 NO. 661
APPLICANT Rt•Fe han NOOP-ra ADDRESS P 1a Str g FjtSth nn
z Np,) (CONTR'S LICENSE)
PERMIT TO New residence (-121 STORY One—family residence NUMBER OF DWELLING UNITS 1
(TYPE OF IMPROVEMENT) NO. (PROPOSED USE)
tip ZONING
AT (LOCATION) Lot #6 Burts Pit Road DISTRICT SR
(NO.) (STREET)
a BETWEEN AND
10 (CROSS STREET) (CROSS STREET)
m SUBDIVISION LOT 6 BLOCK SIZE R X 6O
a
O
V BUILDING IS TO BE 24 FT. WIDE By 36 FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
¢I
O
z TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
I (TYPE)
fK
O- REMARKS: see glans for Lot #6 Clements Street Cane style
AREA VOLUME ESTIMATED COST $ 22,000 FEEMIT Q 66 00
(CUBIC/SQUARE FEET) ,A
OWNER John Tobin
BUI N PT.
ADDRESS RPD RRawrvoi r Rd Wpugt ampt nn, Ma. BY
(Affidavit on reverse side of application to be completed by authorized agent of owner)
NOTES and Data — (For department use)
1
CITY OF NORTHAMPTON
OFFICE OF THE INSPECTOR OF BUILDINGS v
212 MAIN STREET ��`_ APPLICATION FOR
NORTHAMPTON, MA. 01060 PLAN EXAMINATION AND
BUILDING PERMIT
z
IMPORTANT — Applicant to complete all items in sections: 1, 11, 111, IV, and IX. �� O
ZONING /`
1/
I• AT (LOCATION) t �� / DISTRICTS
LOCATION (NO.) (STR ET)
OF BETWEEN AND
BUILDING (CROSS STREET) (CROSS STREET)
LOT
SUBDIVISION LOT BLOCK SIZE 5 U
N
II. TYPE AND COST OF BUILDING — All applicants complete Parts A — D
A. TYPE OF IMPROVEMENT D. PROPOSED USE — For"Wrecking" most recent use m
M
1 X New building Residential Nonresidential
2 Addition(1 residential, enter number
f 12 One family 18 ❑ Amusement, recreational
of new housing units added, if any,
in Part D, 13) 13 Two or more family — Enter 19 ❑ Church, other religious
number of units— — — — --o- 20❑ Industrial
3 ❑ Alteration (See 2 above)
14 ❑ Transient hotel, motel, 21 ❑ Parking garage
4 ❑ Repair, replacement or dormitory — Enter number 22 ❑ Service station, repair garage
5 ❑ Wrecking (if multifamily residential, of units ——————— — -i
enter number of units in building in 15 ❑ Garage 23 ❑ Hospital, institutional
Part D, 13) ❑
16 Carport 24❑ Office, bank, professional
6 ❑ Moving (relocation)
17❑ Other — Specify 25 ❑ Public utility
7 ❑ Foundation only
26 ❑ School, library, other educational
B. OWNERSHIP 27 ❑ Stores, mercantile
8 Private (individual, corporation, 28 ❑ Tanks, towers
nonprofit institution, etc.) 29 ❑ Other — Specify
9 ❑ Public (Federal, State, or
local government)
C. COST (Omit cents) Nonresidential — Describe in detail proposed use of buildings, e.g.,.food
processing plant, machine shop, laundry building at hospital, elementary
10. Cost of improvement................ ) I//,) school, secondary school, college, parochial school, parking garage for,
department store, rental office building, office building at industrial plant.
To be installed but not included If use of existing building is being changed,enter proposed use.
in the above cost
a. Electrical.....................
b. Plumbing .....................
c. Heating, air conditioning..........
d. Other (elevator, etc.)............
11. TOTAL COST OF IMPROVEMENT $212-Gf� a
III. SELECTED CHARACTERISTICS OF BUILDING — For new buildings and additions, complete Parts E — L;
for wrecking, complete only Part J, for all others skip to IV.
E. PRINCIPAL TYPE OF FRAME G. TYPE OF SEWAGE DISPOSAL J. DIMENSIONS �.
30❑ Masonry (wall bearing) 40 ❑ Public or private company 48• Number of stories................ /YO,
31 Wood frame 41 7� Private (septic tank, etc.) 49. Total square feet of floor area, 7�p
all floors, based on exterior
32 Structural steel dimensions ..................... L
33 ❑ Reinforced concrete H. TYPE OF WATER SUPPLY
34 ❑ Other — Specify 42 Public or private company 50. Total land area, sq. ft.�:J.�> l��
43 Private (well, cistern) K. NUMBER OF OFF-STREET
PARKING SPACES
F. PRINCIPAL TYPE OF HEATING FUEL I. TYPE OF MECHANICAL 51. Enclosed ......................
35 ❑ Gas Will there be central air 52. Outdoors........................
36 ❑ Oil conditioning? L. RESIDENTIAL BUILDINGS ONLY
37 Electricity 44 ❑ Yes 45 ® No 53. Number of bedrooms.............. `
38 ❑ Coal p
39 ❑ Other — Specify Will there be an elevator? FulI...C......
54. Number of
46 ❑ Yes 47N_/9 No bathrooms
Partial.