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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 780CN4R 108.3.4 to
act as his/her construction sup�� : 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 family
dwelling, attached or detached structures accessory to stich 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.
Date
Address of work
location
zZt �-
'(1
m llEP/1RTMENT Of' INSPECTIONS
212 Maul Street gunicipal Building
Nortliampton, Mass. 01060
WORKER'S COl'pI ENE SATIONr 1NSUIZANCK' AAIi'I+II)A IT
1, ------
%vllh a principal place of busiress/re ineuce
l67 ;RU. ' �
------ 717�"-
do llCl'CUY Ccr-ul�'• Inn'l':;1 thc' p<1111E ;inn pen 1tIC5 Oi pCI�11I�' ?.I1flI: -
I ^nl an CII1ployci- providing the 10110%viIlt '•'.'O;t;Gr$ col19pcilsaU0I1 COYCr?.' C i01 illy
employee wor1drig on this job:
(1115'1I'3r1G: COt1p2IIV) C_1Cr Numbcr) ---- �Y.}T:r::i1^A Dac)
! j I ant a sole propnc tor, -Jentral con-nc`cr (cu c!e Oat) and 't:av hired
the contrgctors listed beio� ;t ho t:�. the `oi ,r� orKers con nen�s on olio s:
(Nla-mc of Contmcu)r) (III=L nc COIF.^`.:ir':�OIIC'i Z1II11•�c`) �--- ; .n:Icn, DzPt'•)-
(Name of Contractor) _ 7r!surinc Comnarnv?c.hc-, Nur.:cr_r; Date)
(Name Of Caa*,TactOr) (II]SI 3I1C^ (_OIDj,;'u'iit011Cr' NUSI;I �11- - 'A�,i, i:r�u Dalc)
(Natne of Cont-actor) -- - (InS razic Cotnriti;rPol cr Num�_*) ___ f1=;:p:-::inn Date)
prapflC'.Ji c': 1:1 ilav, im )I" ?ilE
I
2111 a hOl11e cv'JI1C•r
NOTE:
not mccc the throc u:nis in u'.:.cii tx k ;ti�..irc rc: u x; .�.•_..:t z _r: r1 Lhcc o e c n<�esrtzilY
czalplcyc3 u-rx'-cr tiv wc:�: fz —._s n,.c:(GLI..52,-z!(Sl';.arr .- :ic;::,y a homco'N�. l for a Lccu ct
legal rtatuc of an o=pIOyer under tLc Wctitiore
I and---stand that a cmy of d ii ctstc::s_•cuy bo fo,—wtlaJ to tln Drtwrt.r e of lyd uuri J. P.c*�1 :�Off;c of i::%iuu:_c for tlx
aovcragc vci iiclioa and that f-ulutrc to:-z;._c cnl-r_;,ut.3;:cGic:25A of l.la,152 can lc--,d to It),inlpositior,of r= pa:�:=�
cvmistLng of a fur_of up to 51.500.00 nnJor ir.:;ui x ;r;!of up to 7r._ duff]xnzttiu in de fima of.,
Lra oC S 1 00.00 a d:y a sitrI stn- .
._ Fcx'cS�%uuzn:sl u.c cnly
:�!(;n:tt Ire Ut ..iCL.11:L!JF'_ r!• ....._�`,� F
0.
SECTION 8-:CONSTRUCT:ION SERVICES
8.1 Licensed Construction-Supervisor: Not Applicable
Name of License Holder :��/�i/9'!BS /V1- rnly'e-ve N 6 2�m d
-� l License Number
/
A dres Expiration Date
Signa re Telephone
9Reere orn marouem'eri't Coat a tore Not Applicable ❑
/YI48L ��F �v�STS�c ->! D,r/ C'r) 1.2
Company Name Registration Number
16 -S- S� (v�,-ti,e �af • C9 ffiq&r14e('/I'( _46 - 9:- d
Address Expiration Date
Telephone
SECTION l0 WORKERS' COMPENSATION INSURANCE:AFFIDAVIT(W G. z 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...... ❑
The ent exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allo ch homeowner to engage an individual for hire who does not possess a license,provided that the owner acts
as supervisor. CAILILft Sixth Edition Section 108.3.5.1.
Definition of Homeowner: on(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 dwelling,attached or detached structures accessory to such use and/or farm
structures. A person who constructs more tha a home in a two-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Officia, a form acecptable to the Building Official,that he/she shall be
responsible for all such work performed under the buildin t.
As acting Construction Supervisor your presence on the job site will be red from time to time, during and upon
completion of the work fo;which this permit is issued.
Also be advised that with reference to Chapter 152(Workers' Compensation) and Chapte 3 (Liability of Employers to
Employees for injuries not resulting in Death)of the Massachusetts General Laws Annotated,vo ay 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 City of
Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTIONSDESfPTrOTVOF PROPOSED WORK(check aTl applicable
Rw
New House Q Addition ❑ Replacement Windows Alteration(s) C3 Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ Siding[ Other[ )
Brief Description of Proposed Work: ca 0 ✓G�iOn �' D ' ! ,fl-JT {.� r0
Alteration of existing bedroom Yes IV No Adding new bedroom Yes ✓ba No / r �y S�
Attached Narrative D Renovating unfinished sement Yes ✓ No
Plans Attached Roll ❑ • Sheet❑
6a l:f Ie`iirhouse and or addit`o fo exist�n °f 0L sin`'" C-om°µ'Le e the fol'1 w :
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? M 0
d. Proposed Square footage of new construction. (d 01.0 [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
SECTTOi�I 7,a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNEkS gGENTOR CONTJACTOR APPLfES FOR BUILDING PERMIT
1, ae k 0 r >L11•//4 �rc) P7 "lg as Owner of the subject property
hereby authorize /Y!Es
to act. on
my behalf, in all matters relative to work authorized by this building permit application.
I m 15121 oy
gn
Siature of Owner Date
LV"i N as / uthoriz�myy
hereby declare that the statements and information on the foregoing application are true and accurate, to the est of
knowledge and belief.
Signed under the pains and penalties of perjury.
. �I,'4vnE A4 mac.v, &I
Pri t Name
Signatur of CAgent Date
i
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
Ibis column to be filled in by
Building Department
Lot Size 13 S-4
JP
Frontage
Setbacks Front o9S ►
Side L: 3 R: 3 y L: 33 R: 3 4f
Rear /IPP 03t l DU �poJc �� ► 30
i
Building Height .
Bldg. Square Footage
Open Space Footage 0/0
(Lot area minus bldg&paved / / 1190
parking)
#of Parkin Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding sever been issued for/on the site?
NO DON'T KNOW V YES
IF YES, date issued:
IF YES: Was the permit recorded at the Regist of Deeds?
NO DONT KNOW
YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO V DONT KNOW
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 Y
IF YES, describe size, type and location:
D. A3,there any proposed changes to or additions of signs intended for the property?YES—
No
IF YES, describe size, type and location:
City of Northampton of .�
��
Building Department f ,
s v+p
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION 70 CONSTRUCT,ALTER, REPAIR,RENOV%1lIT O S A_ N�O 1,,�FAMILY DWELLING
fay.
2
SECTION 1-SITE INFORMATION L
ff
1.1 Property Address: � r �
i be c mpteted by office
�r0.L�St
x r
r vrr VAA, O 10 6 Zone Overlay Da�sttNact
r EltnSt�Distinct CS District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Mar k 1 0, 1 la,"_ �r' d VA *n ,�a rr�� .S 9 6,o v,
Name(Print) I ., Current Mailing Address: .
ti�gnature
Z, C/WfU Telephone, /• ��
2.2 Authorized Agent:
J4-Ma`s /Vi Ld,fv 16`7
N e(Print) Current Mailing Address:
\ /&WLL.4�' &' d
Signatur Telephone i—Lo
SECTI N 3-_ESTIMATED CONSTRUCTION:COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building &0 (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) !D^�, d`� Check Number —`
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-1197
APPLICANT/CONTACT PERSON JAMES M GALVIN
ADDRESS/PHONE 167 SOUTH SHELBURNE RD GREENFIELD (413)775-0120
PROPERTY LOCATION 199 BROOKSIDE CIR
MAP 36 PARCEL 114 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
BuildinjZ Permit Filled out
Fee Paid
Typeof Construction:_CONSTRUCT 10 X 20 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 071422
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF94MATION 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 Commission
jr z zoo
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.
I99-BROOKSIDE CIR BP-2004-1197
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 114 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:ry: BUILDING PERMIT
Permit# BP-2004-1197
Project# 35-2004-1800
Est.Cost: $4000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: .License:
Use Group: JAMES M GALVIN 071422
Lot Size(sq. ft.): 16814.16 Owner: CRONIN MARK A&HILLARY L
Zoning:URA Applicant: JAMES M GALVIN
AT. 199 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
167 SOUTH SHELBURNE RD (413) 775-0120
GREENFIELDMA01301 ISSUED ON.611104 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 10 X 20 DECK
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 Sianature:
FeeTyDe• Receipt No: Date Paid: Check No: Amount:
Building 6/1/04 0:00:00 1259 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo