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DEPARTMENT OF BUILDINIG INSPECTIONS /=
f
INSPECTOR 212 Main Street • Municipal Building '>a
Northunpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sup,:, ,ii:;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 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
understand the above.
(JI Or°own.er/resident's,Aft-rrature.requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
R� yE Crif �f Tc� fllai)1}Itolt _ _— _
R-. � �Zcainrflnsrlte' _
w o DEPARTMEW7 OP DUILDD\10 INSPPC'r1o1.'S
212 Main Strcct ' Municipal Building
i
Northampton, Hass. 010GO
%NV O MCE I Z'S C O NQ'ENS A`ITO N M S URAN CE AF"I-D�AVIT
(licc'as:xJperm�ticc)
%VlLb a principal place of business/residence at:
— (phone_,)
iy/stalLfa p)
do hereby certify, under tlie.pains and penalties of pc 'ury:; hal
( ) I am an employer providing the followine worker's comoensado, cove mge for In-y
etuployccs wor_Ung on Uiis job:
1
(LanLran= Comr.2) (Polic: Ku_mbcr) --- (r:-piratior, Dzte)
I am a sole proprietor, general contractor or homeowner (c cie one) and have hired
the contractors listed below cgbo have the foilo%ving worker's roLoen_sa 'on policies
(In urancc Cornoi-I)vi'oue; Datc)
/t l
� l
(Name of Contrctor) R s-u.raac� Comp-anyi?o lei Nttmcnr) Date)
i
(Name of Contractor) (Insura.ncc Compan)-/PoLiq- Nambzr) (l:cp r:aen Date)
(Name of Contractor) (Iasuran Comcauy/Poliey Number) (E��irtioa Date).
(attars_dditio¢J 6c-ct to iaror=n :ioc pczta.iaaas to'D o==-ran)
( ) I am a sole prop[it;tut and Dave no one worldng for me.
( ) I am.a home owner performing all the work myself.
NOTE:plesc be ew71-e t.3:�'FaJe bcc ev -acra wbo eraylay pcsotu w de c-;•",-,• ea�.tiao c rgau Work w.d..ttt:-Z of
- oedi ant more he L` � S is%X the bmoo'ws r=do«oa the z7rec.c DO(cr:Uy � w be
eitployct unGc the-=k: 0--,'ca Aa(GLI52- 5)�aPDlia000 by n 6ommaoer fea a x.a pcma rz y e id�oc tl e
Icg!
0--of—ex.Toyer uodar d�Wockorr Coa**c=uGoo Act-
1 uodc*s+ad tba%copy of this c=cmccd oa.y tie for.v%i>d to the Deportment of lnduuicl Aond� OM or lrsa��for th.
cov .T vctit-t=tioe am ttu L-.iliac to"O=tox-cr AZC under zxtion 25A of h(OL 152 ran ied to the is;oseion of cimi=l pcatli em
oo=,%mg or a fiat or up to S 13oo.00 and/or ctprisGooey of up to co,y,-,r e.nd coil peas.hia is t.roan of a Stop Work Ord-- &ad a
rl=of S I0o.00.d_y Lpimt tars
For dcp.rtm=s1 u,c only
/"D ��, � � �l Permit Numb=
),.{3p°-- Lot
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9 teasereFlomenpoYeifeno�t ar;tor� k t " Not Applicable .❑
ME
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...... ❑
ego
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-vear 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.'
A��-
1
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑] Addition [❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[0) Other
Brief Description of Propose
ork: �-J J�'EASoN ht 13.46 OPEN A CK 1, X/6 RE94LE d SEPIA 2,-AY,4 'fT.cxt5 1ff
Alteration of existing bedroom Yes_ ly
L No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet
kW " Ns ftew o b iit6ffl4 , l � fds se Eeg fa�nrrr�p:
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.RM nLIJd~ 111mensions RN ji& V 4,,K JJ)eJ4
e. Number of stories? l
f. Method of heating?—f P Lc�j2 Fireplaces or Woodstoves -, f Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
L Is construction within 100 ft.of wetlands? Yes _ X No. Is construction within 100 yr. floodplain Yes g_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 1/\ Private well City water Supply _
SECTION 7a-=OWNERAUTHORIZATION-T0 BE°COMPLETED-WHEN
OWNERS-AGENT'OR CONTRACTORAPPLli S fOiZ EiOIIbtN:G PF-RMIT`
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 as Owner/Authorized
Agent hereby declare that the statements and information 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
.Sigtire. Ghvnerl Date
. �
^
-
,TSjec�tio�n:4.
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear vo
Building Height
Bldg. Square Footage %
Open Space Footage % �q^ L �^
(Lot area minus bldg&paved L-------j
#of Parking Spaces
�
'
A. Has a Special Perm it/Vahunce/Findi ng ever been issued for/onthe site?
K;N �� ����
NO v�� 0ONTKNOVV �~� YES
IF YES, date issued:
IF YES: Was the permit recorded atthe Registry ofDeeds? '
��
NO �� DON7KNOVU 0 YES
IF YES: enter Duuk Page' and/or Document#| i
'
x�� x��
B. Does the site contain a brook' body of water or wetlands? NO <y DON7 KNOW v_� YES ��/
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tmbeobtained Obtained »~� Date. . .
�� tick C. Dn any signs exist on the proper�V YES ^�� NO LA/
IF YES, describe size, type and location:
-
D. Are there any proposed changes toor additions nf signs intended for the property? yB0 NO tGN
IF YES, describe size, type and location:
E Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre nrioit part nfo common plan
that will disturb over 1 acre? YES K � NO
��
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
xis r as D ar AeE3 SeAn '�
City,of Northampton
�Iding Department
r' �� �� Q Jf� ," ��12 Main Street
i Room 100
A�G 2 8 2006 No 'mpton, MA 01060
phone 413- 87 71240 Fax 413-587-1272 s �
p� i ka t
APiLICATION.FOPRO(NSTRUCf,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE;INFORMATION
7bi�.s section to be completed by office
Mpert:4 Address: r
4VIapt
36 OOKsIaF
Overlay i?�strc#
,Elrta"Si:`Drstr�ct -` ... C�.I]istuct ' I
SECTION 2-PROPERTY OWNERSHIP,/AUTHORIZED AGENT
2.1'Oweer cN Riagcrd'r'
A 4-r a- s &�7 )UPOx e sips' ��R
Name(Print) Current Mailing Address:
�y- ; 603
f Telephone
2.2�Authorized Agent:
� /
Name rint) Current Mailing Address: 0/08
ignature Telephone
SECTION:3-ESTIMATED�CONSTRUCTION rCOSTS`
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Bpilding'Permit Fee
2. Electrical (b):Estimated Total Cost of`
Construction from 8
3. Plumbing Building'Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number !�o
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2007-0222
APPLICANT/CONTACT PERSON BASILE NATALIE D&JOHN LEARY
ADDRESS/PHONE FLORENCE �8y _(�603
PROPERTY LOCATION 327 BROOKSIDE CIR
MAP 36 PARCEL 134 001 ZONE URA� ,���
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: CONSTRUCT 13 X 16 3 SEASON RM&OPEN 12 X 16 DECK&REPAIR ROOF
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 LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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-2007-0222
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma D:`I`,,, k�:�36 13* CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2007-0222
Project# JS-2007-000339
Est. Cost: $25000.00
Fee: $59.60 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Homeowner as Contractor
Lot Size(sa. ft.): 28183.32 Owner: BASILE NATALIE D&JOHN LEARY
Zoning:URA/WSP Applicant: BASILE NATALIE D & JOHN LEARY
AT. 327 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
327 BROOKSIDE CIR (413) 584-6503 ()
FLORENCEMA01062 ISSUED ON:813112006 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 13 X 16 3 SEASON RM & OPEN
12 X 16 DECK & REPAIR ROOF
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 8/31/2006 0:00:00 $59.60699
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
«�
.�:. _ __
_� _ _ -�;� ----� w _._,
4
327 BROOKSIDE CIR BP-2007-0222
GIs#: COMMONWEALTH OF MASSACHUSETTS
Man:Block: 36- 134 - CliY OF NORTHAMPTON
Lot: -001
Permit: Building
BUILDING PERMIT
Permit# BP-2007-0222
Project# JS-2007-000339
Est.Cost:$25000.00
Fee:$59.§0 PERMISSION IS HEREBY GRANTED TO
const.Class: Contractor: License.
Use GTOIR: Homeowner as Contractor
Lot Size(sq ft.): 28183.32 Owner. BASILE NATALIE D&JOHN LEARY
Zo►iug URA/wSY A nlp scant: BA�ILE NATALiE D &JOHN LEARY
AT.-327 BROOKGtDE CIR
r.-
Aopiicant Address. hone: Insurance
327 BROOKSIDE CIR (413) 584-6503 ()
FLORENCEMA01062 ISSUED ON.-&3112006 0.-00:00
TO PERFO"If THE FOLLOWING WOR':CONSTRUCT 13 X 16 3 SEASON RM & OPEN
12 X 16 DECK & REPAIR ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STRt�:ET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings: {,, 1 n,-�'. 0"i (7
Rough: Rough:&)-/�/_(j� House# Foundation:
2 Driveway Final: 9
Final: Final: Lp owv�
^+ Rough Frame: 10k tot('
/?[0 b Lows
Gas: Fire Dew9rtment Fireplace/Chimney:
Rough: Oil: Insulation: bJ{ Ib - 6 c� f-fs"ii
_.�_� # _
Final: melk : Final: dj, (21/61 06 L0•4t
S
THIS PERMIT MAY BE REVOKED BY Tip,CITY OF NORTHAMPTON UPON VIOL ON OF
ANY OF ITS RULES AND REGU TI
Certificatg-of Occiu )ancy Signature;
FeeT,ype: Date Paid: Amount:
E
Building 8/31/2006 0:00:00 $59.60699
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo