36-040 (2) WiNDOW WORLD
Leeds, MA 01053
Telophone 586-8712
CONTRACT
This agreewQnt, between,
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DEPARTMENT OF BUILDI7\'G INSPECTIONS /=
INSPECTOR
'212 Main Street • Municipal Building
Northampton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNlR 108.3.4 to
act as has/her construction sup, ,`isor. 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 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
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.
Daze
Address of work
location
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w DEPARTMENT OP BUILDD-,10 INSPPCTj() S
212 Train Strcet Municipal Budding
Northampton, Mass. 01060
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WORla-R'S COI�II'ENSATTON IiISUR CE :�ITIJ�� .Z��
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I (li ceusxlprnni tt'cc}
With a principal place of businessfresidence at; ---- - -
s� J/frytocic_.s �� , M �fos- (phone.') 7i �
do hereby certify, under ctie.pam 2nd pen2ities Of per-ury, -hat
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( ) I
am an employer providing the following!worker's comocnsaLion cove se for Inv
em pl.oyccs woriang on tubs job:
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0-asl=�D=CO[Mr-am') (Polio:Nu-MIX-r) -- FE-;pinyon Dates)
( ) I am a sole proprietor, general contractor or homeowner(ci c;e one) and have hired
[he coniractgr-s listed below wbo have the follo� 'p worker's coE,2oen_20ion pc!�cies:
Oi Con�rncwr) (lnsurancc Compan)'l-Pobci N1LL ti--r) (Expinauo Datc
(N me of C001=10r) 01]S 72-OCC CoMnaayr-Po!ic,- \tuncrr) (1 a�±rtion Date)
(Name of Connac[o;) (Insurance.Compan}•/POlic)• Num-b:.r) (Expiraoo Date)
(Name of Contractor) (Insuraac� Company/Policy Numl s) (Expiration Date).
(arxac3i�oc3.t r'�ca,ifncxz�.y to inc!u��iarortaa.aoa Pcu�iaza6 to.11 noon-_cn:-�) -
a sole proprietor and Gave no one working for me.
( ) I am,a home owner perforTn.ing all the work myseif.
NOTE:Pl=�>x ccrirc tt,. t lc txmr�.avc s vt-0 cZ=Play P�xom w do c-s cs ciao r rcpair work oa L d..clLg of
ant rnai th a t,'soe t�i�is
-Eh ttx botnoowocr raid.o<oo the p-ou> zp7jxt,n—tbeev r c ooc C=� -tty oocr_dard to k
'Ployes un~the.. _ _ *on ALt(GL'1 S2 a I t5)) pplic boa lry n homn3ax fc c Gc�.or permit r_y e�idmoe the
Ic gel n� ,,of ea<t=Ployx under dtn Wockc e,C,003P�Ad
[undcsssad tba a copy orthil m.y b< w LE.Dcpsrtmma or[ r;rl Ad—&o1m.Or6uuwoe for tbe
cova-Fe ra'iLeaioo and ttu L;ltae w s«,uc to---gc tr&-=z;on 23 A of htOL 1.51 c�tcLd to the iq;o oa of aimiaA P-16
coosc:mg of a tint orup to S 1.300.00.,Wcx imprisoam�orup to o«y.rand c.il pm..tia is d.form of a Stop Wort;Ordc r and.
rim of s t oo.00.d_y•pciast QY_
For dcs.rt¢. -
�h
Pcrmtl)`t t1IDtX:r
tatum of a�scrJPccmiucc e
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SECTION 8-CONSTRUCTION SERVICES 1J
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9v�teaisfe`re�klo"rn Not Applicable ❑
Company Name Registration um er --- _—
AM cc.16
Address Exp•ation Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIQAVLT(M.G L.c:152,;
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...... ❑
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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
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SECTION 5 DESCRIPTION OR PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement,VVIndows Alterations) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[O] Other[[31
Brief Description of Proposed--
Work: -f u ,t f�Ll Y� If J +V''f r c-✓J(- C:=PX a"-a -S L-' f/*L, 'S S
Alteration of existing bedroom Yes No Adding new bedroom Yes _No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa-4V N6 l ouseran&b"WditiQ6�to exMtthir hO sIfi mco tilei t[i �Favr ina:
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. tloodplain 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 Owne uthorized }
gent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my-`k�wTedge
belief.
Signed under the pains and penalties of perjury.
Print Name
Signatu wned n 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
Frontage -- —
Setbacks Front
Side
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?
N0 Q DON'T KNOW Q YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page; and/or Document#' I
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT 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:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q
' 4
IF YES, describe size, type and location: j
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 O , NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton =Peas �' �•
b Building Departmentvewa
212 Main Streetrwuve
Room 100 � � r ell yarfab ,
IF
Northampton; MA 01060V Ses o5tetta,ss1
phone 413-587-1240 Fax 413-587-1272 PIoS te�fans
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APPLICATION TO CONSTRUCT,ALTER, A OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION "
rs sectIbn,to be completed by office ';.
1.1 Property Address:
Ouerla "D' tfidt
Elm Sf.Dslnct .? CB Dstr•,ct -•°' =, '
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
AL-L e 4 A,AA_ 16, G AT r-/i
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
nature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
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) Check Number
This Sectiom'For-OffciafUse Only
Date
Building Permit Number. Issued:
Signature:
Building.Commissioner/inspector of Buildings Date
1067 BURTS PIT RD BP-2005-0894
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36-040 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0894
Project# JS-2005-1240
Est.Cost: $2335.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq. ft.): 12501.72 Owner: EKLUND ALLEN C&VICTORIA A
Zoning:URA Applicant: John Corbett
AT. 1067 BURTS PIT RD
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON.3124105 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 3/24/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo