35-210 (3) 11 iAM p�
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Gitp of Nartllamptan
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� DEPARTMENT OF BUILDING INSPECTIONS F
INSPECTOR 212 Main Street Municipal Building e
Northampton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 1083.4 to
act as i.is her construction sup . �:,or. Th,0 sta:c, defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or hvo 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/footiny-s (before backfill),
sonotube holes (before pour), a rough buildinjZ 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, a -S 14/411,. � -' 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 E 3 a
Address of work 0A
location low �_�
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1oY'tMic,2 /Vt 01062-
�EI'AR"I?,1 T OF, L•ilII1�11�C INSPF.C-11(�P:S
212 Train Street Municipal I3uikinl-
NorthalM)ton, Mass. ONTO
wor�rtlt�l;�s CONI-PENSATION >Nsvr?�NCY, �rtFYD,�VIT
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v,,il l a piiiicipal plant of busnesdIC:;Idence vi_
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the Gofltia ctoi-s liS1_ed blow who have the folenny VMACKS cumunnsnm Phnns:
(Nan:_ of(-�,I_rn AniuFant. V:OwPVnT&Ky "I�,,.._:' , DMC)
WIN C Of An 20:; !1 Diu W C_o?i.. a:-iy" '!l."t
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(Name of C,on.hc.or) �iasZ.c�stc Cony. _.� ,roi, ,� Numh-°�l Date)
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.� I.-;>Ic-sc be nn�;c L:�' .�;:�; f _.:r_n�:r_n��.h;card:. .� - ..rsi .:: .,.. � • .. �-_ ...,•.
rot,^.tcc-c tlrn ltLCO ut:ht u'ui:c'_t::r:�..r',.n�2,-r rc�::a c�<xi!`�.-r - ::'_�z,,. r.�,__�LK�..,r::n<[;:'�-r l.;r�-•.�.: _ ..:�h-
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API clam;of nn—rphyx under dm LL'«}«'�Co v;xrriion rt
I ut Mind thin-mhy of h_a r_.xy t�fcn—ud«l to tl o Dtjxi t: -xi of Lr iu_ti:ri:�Aci�-r.:�CfGc>7. o...-- .-c for U.
crovcra��c v4�irc�licxt n.'td taut f�ilt:rc to�..uc cv�ttz�ut;S:r�:irr 25 � t ��:
�`OQltsting of n fiir_of up to S I.SQO.(YJ i:�.'(x ir.:�ri:<xz_R._:*oCup to cn'}t:r n:�j dvil Isrultia in dr:cmn o(n:;tr,,AVni�_(}�'-,and a
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SECTION 8 -.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : ---
License Number
Address Expiration Date
Signature Telephone
9Registe"red Nomelmpr(svemeni Contractor. ,, a ,,,, `,,, ) _„ 4 Not Applicable ❑
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...... ❑
11R3'ome OR%nerxe ption
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 __
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ')K Demolition❑ New Signs [ j Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: O f'8 --
Alteration of existing bedroom Yes No Adding new bedroom Yes No L/f4
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0 --
66:1 f:New house antl,or'addition'to existing-hdusing, complete:the followink:
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
OWNErtS„AGENT'OR CONTRACTOR APPLIES FOR BUILDING PERMIT
JA 1AAt5 �L/ J as Owner of the subject property
hereby authorize mlkn%, _ to act or
my behalf in all matters relative to work authorized by this building permit applic tion.
Signat of Owner D e i
as Owner/Authorized Agent
hereby declare that the statementsLdWinformation 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
i
Signature of wne Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
fSizeD DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
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: 74T3
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 DON'T KNOW
YES .
IF YES, has a permit been or need to be obtained from the Conservation Commission?AJO
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:
Mg
It, Ity of Northampton Satus�oermf#s
f.�. Building Department Gu�rb�CtlD=ire �.
,2.12 Main Street SewerlSep�ic
M AY 13 2003 Room 100 W61rd W AVdt � .
Northampton, MA 01060 T,wosetftr. e urn Pa; � �� � �
hone 413=587 1(240 Fax 413-587-1272 Rlot%Site Pfans �� j
xA� • - ti°° '���' � ''
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Other Specify 117 ' , ,
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This.sectlon to be-,complet64 by office- ;
Map Lot Unit
�I A Vi
Zone Overlay>Distnct
office- M A 01 62-
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
_ __ ��>~°S Grv ►��- qd g dean R,o1 �'lovrc� M.� 010_ Z_
Name(Print) C,rrent Ma?iihnn`o Address:
Telephone
Signet -- —
2.2 Authorized Agent:
I
Name( ri ) CL,rrent Mailing Address:
Signat, Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit a hcant
1. Building (a) Building Permit Fee
O
2. Ele:.ii ical Al. Zia s (b) Aimated 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 c v�
This Section For Official Use Only
Building Permit Number: lS�'-f Date Issued:.
LSignature: _— ---- _ --
Building Commissioner/Inspector of Buildings Date
File#BP-2003-1014
APPLICANT/CONTACT PERSON GUGGINA JAMES
ADDRESS/PHONE 908 RYAN RD (413)587-9410()
PROPERTY LOCATION 908 RYAN RD
MAP 35 PARCEL 210 001 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
Typeof Construction: INSTALL WINDOWS TO BARN FRAME CEILING&NON-BEARING WALLS,
INSULATE SHEETROCK&INSTALL OUTLETS&LIGHTS
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 F9CLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO,P4ATION 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 CommissA
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.
BP-2003-1014
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2003-1014
Project# JS-2003-1619
Est.Cost: $5000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 43995.60 Owner: GUGGINA JAMES
Zoning: SR Applicant: GUGGINA JAMES
AT. 908 RYAN RD
Applicant Address: Phone: Insurance:
908 RYAN RD (413) 587-9410 ()
FLORENCEMA01062 ISSUED ON.5 115103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WINDOWS TO BARN, FRAME CEILING &
NON-BEARING WALLS, INSULATE, SHEETROCK & INSTALL OUTLETS & LIGHTS
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• Receipt No: Date Paid: Check No: Amount:
Building 5/15/03 0:00:00 1937 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo