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DEPARTMENT OF BUILDD\1G INSPECTIONS
INSPECTOR 2'12 Main Street • Municipal Building S
Northampton,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 sups: -:7; 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 fa►ft17y_ -
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 eegulations. 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
/re "uired can DELAY the project until such time as the proper permits and inspections are
de
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
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w`d DEPART ME1 rT OP BUILD0\1C MSPPCTIot"S ;
212 Alain Strect Municipal Building,
ll'orthampton, Mass. OIOGO
WORKER'S CONIfP ;NSATTON GetSURANC- AJ7F )r1AFj-j-
j
(liccnsxJpermltfcc) .. --- ---
%%IlLb a plL,ncipal plact of businesafresidence at: - ----- - -
(phone=')
(scr�t/c�rr/siaul a p)
do hereby cerdifjr, under Cie pains :md penalties of perJury, ihal
( ) I am an employer providing vie Followine!workces comocnsaio, covervse for Im
employees working on uiis job:
I
Conrz-zv) (POt1C: Nu.._r) -- (t .-pinion D2j--)
O I am a sole proprietor, general contracor or homeowner (cu tie one) and Lave hired
the contractors listed below vybo have the 150k%viog worker's coi Jen_�aaon policies:
i
(i+`SID: of Con.I=Or) (Inst rant Comp3sipp06Ci ?�tt1II1.C:) (E.NpIrdi?^n Gale)
(Name of Contractor) (Llssfanec. Como_ zvlpo!icti, Numc_r) (Lipir6on Date)
(Name of Conuacto,) (Insurance. Compa=yipoL-cy N;tsbcr) (Expimaos Daic)
(Name of Contractor) gas-ara.ncz- Comcauy/PoUcy Numb`r) (Ex�italian Daft).
(att1 CK3J Ucet,ifncoaz�•to mc?ud iaf«a.�oa pcu:�to all
j O I am a sole proprietor and have no one working for me-
% I am.-a home owner performing all the work myself.
NOTE:plese be aaruc Lt,wjijs hemeoµvcra.abo ez=ploy peso=w do rcpau work oa.d..c1L•Z of
any mote tb-- L"ter.,in uzaeb the bomoaw•oer r,,<da a oo the QoaacS z,purLca:=tbeen a.-e we V=r.Ay occrd=d to be
exxploy' (be"vr c`z r=.'+,--+:oa Act(GL!152=1(S)),=ppli=600 by a bomcoa-o=for:bcs_or pcmit r=y a id--aoc the
1-P1 its�u or crployar under Qro C,oc:,.m Lion AFL
I uodcsiaad tba a copy of Qua-my be foc-z.crdad to ttw Dcpartz:a:oa Ac dcc&ofG..of 4.u+oce for tbo
ooveuse rciratioa a td th s C ilt-m to sccurz tov,a&C tnldc sc=ion 23A of htOL 152 na led to the i=pnsiion of eimiail Pct 16o
000sising of►fine or up to S 1 500.00 andlor ixtxpeiy oCup to ooc ynr sad eiva peaateio is the form of s Stop Work Order and.
fim of S 100.00 z dty splwi mC
\ Fa{7.rca��st ux onJy
\ permit Numbcx --
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1..(2p° Lot
SiBnaturc of Lio=scrlPcrrnittcc e 1
SECTION;8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9': tev�s of re .Pome�lmn AH—Li"�t on a k Not Applicable ❑
Company Name Registration um er — -"
Address Expiration Date
Telephone
SECTION 1'0-WORKERS'COMPENSATION INSURANCE AFRIDAYjT(M.G L.c.fi52;
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-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 Ail]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 L r a , � zy
/
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SECTION 5-DESCRIPTIONrOF PROPOSED WORK(check-all,aaalicable1
New House Addition Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [pj Decks [C] Siding[0] Other[dj
oie'Description
/�'�pose
/ _.
Alteration of existing bedroom Yes_ No Adding new bedroom i' Yes No',
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet /J f—
mom,., = °na,... .,,xi.:Cs".;, ;a';ti:..-F°w i; �i _ r 'rp;. xr:n-;-u, •.:u"- '".
sa: ev use a ff ° dd �a # e�c�s: a O sln :om et the �Cl ari�rn :
a. Use of building:One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms_.2-
c. Is there a garage attached?
d. Proposed Square footage of new construction. / G Dimensions r �,
e. Number of stories?
f. Method of heating? C— Ar c e L Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction (2,)<
L Is construction within 100 ft.of wetlands? Yes �o. Is construction within 100 yr. floodplain Yes_ZNo
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-OWNERAUTHORIZATION-TO-BE COMPLETED WHEN
OWNERS.AGENT QR:CONTRACTOFTAPPLlES FOR BUILOING;.PERMIT
I, j'q A.,2,wQ T rILK q A M as Owner of the subject
property
hereby authorize S.4rVp ice �i N►ri�El(Nt
to act on my behalf,in all atters relativd to work authorized by this building permit application.
W nature of Owner Date
I, �5Aji 4,1 A e,4 J /i 1:416" ,as OwnedAuthorized
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
-- - :�,s
Signature of Owner/Agent Date
Section 4. ZONING All Informat.i6h 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
#of Parking Spaces
(volume&Location)
A. Has o) Perm it/Varianca/Fndi ever been �suedfor/on the s�e?
NO' 0 DON7KNOVV 0 YES 0 �
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO K ] DON7 KNOW U YES
IF YES: enter 8ouh Page' and/or Dooument#
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B. Does the site contain u brook, body of water orwetlands? NO �~��� DON7KNOVV �_� YES �_�
IF YES, has permit been or need to be obtained from the Conservation Commission?
-
Needs tmbeobtained x-� Obtained /~x��� Date' �
C. Dn any signs exist on the proporty �� ��V 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 0 NO 0
'
IF YES, describe size, type and location:
E. Will the construction activity disturb grading,excavation,or filling)over 1 acre oris it part ofo common plan
that will disturb over 1 acre? YES K } NO K �
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(F YES,then o Northampton Storm Water Management Permit from the DPW is required.
-------Qty of Nortf ampton r ;
�"Building Department
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212 Main Street
Room 100 -�
APR 2 7 200 Northampton,;MA 01060
phone 413-58V-1240 Fax 413-587-1272
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AF1PLICATfON TbCOAISTRU8T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITEJNFORMATION
1 Property Address
Thts secfion to be completed by office
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dot unit
f141'r-0v CF �� �/ 6 Zone Overlay D�stnct
°Elm S>~Dlstnct g � CB D�stnct 3
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SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
fit Telephone
Signature
2.2 Authorized Agent:
Name(Print) 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 (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 0
This-.Section For Official Use Only
Building Permit Number. -Date ,
:Issued:
Signature: r
i
Building Commissionerlinspector of Buildings- Date
File#BP-2005-1053
APPLICANT/CONTACT PERSON GRADY FRANCE&SANDRA PINKHAM
ADDRESS/PHONE 348 WESTHAMPTON RD FLORENCE (413)584-8050 Q
PROPERTY LOCATION 348 WESTHAMPTON RD
MAP 36 PARCEL 199 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
T_ypeof Construction: COMPLETE FINISH WORK ON DORMER
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Buildin¢Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE F9LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF99MATION 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 Commi ion
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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.
348 WESTHAMPTON RD BP-2005-1053
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36- 199 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2005-1053
Project# JS-2005-0781
Est.Cost: $3000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor. License:
Use Groin Homeowner as Contractor
Lot Size(sq. ft.): 294901.20 Owner: GRADY FRANCE&SANDRA PINKHAM
Zoning SR Applicant: GRADY FRANCE & SANDRA PINKHAM
AT. 348 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
348 WESTHAMPTON RD (413) 584-8050 (�
FLORENCEMA01062 ISSUED ON.512105 0:00.00
TO PERFORM THE FOLLOWING WORK.-COMPLETE FINISH WORK ON DORMER
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 5/2/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo