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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '>a
94 S��y
Northampton,MA 01060
r
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 super.' :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 fay _-
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 boil Ing department forfhe City oTNorthampton-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 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
x—, � understand the above.
( ome owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued-to me
Daze
Address of work
location
r
(riff aftzz-flIanlpiOil �T
$ ' E - �Z:�alcrhnsrlla' �
w c� DEPARTMENT OP DUILDI')\10 INSPPCTIoN.S _
212 Alain Street Municipal DwIding
Northampton, AT ass. 01060
«'ORI-aj1 'S CON=, NSATIO.N MSURAJN CE Af'F=,,i V-1-I'
—_A --
(1�ccnsxlnc;m�cicc)
prblicipal place ofbusinesslr sidenc, at:
/'M 13
(M-c--U6 ty/=r-lzip)
do hereby certify, under the pains and penalties of perjury, ----hal
O I a an employer providing the follo%viniz'Workcrs cornocnscdon covem�c for my
m
etnplovcts worlong on uus job:
(Lr -n= Corer.-) (Polic-,?:umbcr) (_:plratior Dan)
I
(' ) I am a sole proprietor, general contractor or homeowner (c de: one) and bave hired
dhe con-actors liste�d below rgbo have the follolvinQ worker's conjen_snon pokles:
i
i
(i+SSI2C Of COnt"Clor) (In51 any C0ITI0,fl)YI'GUCi !4417=-:7)
— (Name of Counc ior) (Lsaran= Comozz-vPoUm, Numnc r) (Ea-Di—muon Dse)
(Name of COUMC-10) Omsuran= Company-/Pot:cy Numb:r) (E.xpirdoo Dalc)
i
1 -
(N2rnL of COUMC10r) (Iflsi== Comrzay/Policy Numb:r) t=xpi-,ioa Dal`). -
(nax3:d:;s�ocal:bc .ja c, •-v to -u3f0raL6oc Pc—U='g to.0 Doer--e—zo.�)
O I am_a sole proprietor and have no one worLing for me.
( am,a home o,vner performing all the work myself.
NOTE:pl=-=be acvxrc ri—v+jjc wbo c.7ploy pczori to rlo r, cs cam c rgxr w-ori on a d.•=U—mi:of
i aot tnorc tti�tt roc t�tJ in t ip the bomoaw nc raid a or ec tb e IIvsn6 z,�ysrtea_=tbero r:ox —�—.11y---d---td w be
ci>ployca ttnG=the�.us c=-,r--,.oa Aa(GL152:s 1(5)�c.pplra7w by a bomooa=fc r tic=v«pcmrt r✓y c ids c tl
lcp!c-mss•of as,.=ploys=ed tbo Wori--!r cocpomaisoo.Aix
i
I uadcs .ad ids n—py of thi.-=,L m may be fo,--:Led to tbo th.
cov=is vcrZc=ion znd a Lilt W sayrc Eoverabe=)d,—==;on 25 A of htQL 152 C3 icy w the L=P a 0a of a imiasl Pe %16a
eoaz.i:.iag of a fiat or up to S 1}oo.00 xmjf mprisocnc,-ri or up to oat yr=r coil pmaY.ia io'�'form of.Stop Work Ord=nod a -
r=of SI00.00 y cv,i>Kt t:),-
For 6cp.rta+11 u.c Doty
Y
ICI-LD.Ii Nt3IIllbC1 L,01
S i gnatirc of Lic:rsrJPcnniu He
SECTION'8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable X
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
1: e sieoliiiem�a emeno>at aco A Not Applicable
Company Name Registration Num er ----- —
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION''INSURANCE,AFFIDAVIT(M.G.L:c,1'52,§25C($))
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...... ❑
l o:
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 be/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 cal Zoning Laws an C or Massachusetts General Laws Annotated.
1,
Homeowner Signature
r
_ r..
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House F-1 Addition Ell Replacement Windows Roofing
Or Doors D
Accessory Bldg. ® Demolition New Signs [Q] Decks [Q Siding[lam] Other[O]
Brief Description o roposgd-
Work: f,iACx 1S'T7 IU6- S CAP- S (/0
Alteration of existing bedroom Yes ✓No Adding new bedroom Yes No /
Attached Narrative Renovating unfinished basement Yes f/No
Plans Attached Roll -Sheet
sa' �N'eirv���iousend� �tlt>t�o eats#nc�ii� s�g:omntete tt�e�fi` Io IQ g:
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
------------
I, u r") a uthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the est of my knowledge
and belief.
Signed under the pains and penalties of perjury.
C
Print Name
Signature of Owner/Agent Date
Section 4. ZONING All Informat+bh 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 — ? '
Frontage (i o 1�
IL,e Setbacks Front D l C
�Kiocl' Side L:� R: L: R: ° ,
Rear
— L
Building He•ght
c -- 0-,� ;s ?) 3 7,
Bldg.Square Footage ! %
Open Space Footage % �/ �7
(Lot area minus bldg&paved Q T ��o l
parking)
i
#of Parking Spaces Z' —
Fill: , %3<D,y
(volume*Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW tiN YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 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 0 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:
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 r NO
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
.KAY :Departm!er"se-on y ,
..City of Northampton StatuaPerarult
�' wilding Department C ate'
212 Main Street
Room 100
Northampton, MA 01060 lari -
phone 413-587,-1240 Fax 413-587-1272 ���
�Y
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE,INFORMATION
This section to be completed byof tce
1.1 Property Address:
R'c
�o tin
AM ( �L1 Zane Overlay Disfricf
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGE,NT
2.1 Owner of Record:
)�911r/,0 1/1C7z�,'l ' ���Ilt<� /d� /3 1/l- i E
Name(Pri / Current Mai in g�Add
res --- 67,32-3
L/ , < Telephone
Signature
2.2 Authorize ent:
Al A
Name(Prin 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 J (a)Building Permit Fee
r
2. Electrical Q (b)Estimated Total Cost of
Construction from 6 _
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) Q
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Secfion For OfficiaC Use Only
Date
Building Permit Number Issued:-
Signature:
i
Building Commissionerlinspectorof Buildings Date
File#BP-2007-0190
APPLICANT/CONTACT PERSON EKLUND ALLEN C&VICTORIA A
ADDRESS/PHONE 1067 BURTS PIT RD FLORENCE (413) 585-0323 Q
PROPERTY LOCATION 1067 BURTS PIT RD
MAP 36 PARCEL 040 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
T_y_peof Construction: REPLACE STORAGE SHED W/ 10 X 10
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 RMATION 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
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-2007-0190
GIs#: COMMONWEALTH OF MASSACHUSETTS
;vY TY:
bk
tc1 3� 64 � CITY OF NORTHAMPTON
Lot: -001
Permit: Building
CateQorv: BUILDING PERMIT
Permit# BP-2007-0190
Project# JS-2007-000289
Est.Cost: $1200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: Homeowner as Contractor
Lot Size(sq. ft.): 12501.72 Owner: EKLUND ALLEN C&VICTORIA A
Zoning.URA Applicant: EKLUND ALLEN C & VICTORIA A
AT. 1067 BURTS PIT RD
Applicant Address: Phone: Insurance:
1067 BURTS PIT RD (413) 585-0323 ()
FLORENCEMA01062 ISSUED ON:812512006 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE STORAGE SHED W/ 10 X 10
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 8/25/2006 0:00:00 $25.001346
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo