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Q DEPARTMENT OF BUILDI]\TG INSPECTIONS
INSPECTOR "212 Main Street • Municipal Building '
Northampton,MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMK 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 yr two famiry-
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
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
r
Flo Gc3""�y� Gib)) of �'Torfl}i3111pf0il
ll C' 31i7aRr}ia6rtlis'
DEpAR I MEl rT OP BUILDING INSPECTION'S
212 Main Strcet Isfunicipal Building
Northampton, Mass. 01060
I
WOR1Vii:R'S CONUENSATION MSUPkNCE A17' MAVIT
(li ccnsxJperm�ttcc)
with a principal place of businessfresidence at: —
(phone-.')
(Sum--uci ty/statctn p)
do hereby certify, under the pains and penalties of penury:, hat
( ) I am an employer providing the follo.vin,;%vorkcr's coinacnsZoo, cove Mge L mY
emplovecs ivor 3ng on tilts job:
I
(In _n=Comr. c)r) (Pelic;Nu-�fxr) (r:'pirsdon Dauc)
I am a sole proprietor, general contractor or homeowner (ccie o:)e) and have hired
the contractors listed below wbo 1 zve, the 50DOWIDg workers caE.2pep_tzhon policies:
(Namc of COf2r^Cior) (Ins rzno^ Coinoai)•/PoUCi Num_r-)
1
(Name of Contractor) (IrL7,=cc ComoaavtPoUm, Nuol nr) (—Exp rtion Date)
(Name of Contractor) (Insurance. Compan)•/PoUq- Namb:r) (Expiroon Daic)
I
I -
(Name of Contractor) (tosuranc–c Cornpaiy/Policy Numb-:r) (Expirtion Darr) .
i (ntv�ad�ocal�cd,irnccai�•w e�c?utL iaforay.,;ioo pertniasus w..11 oc�-r�:�) .
am a sole proprietor and have no one working for me.
( } I am,a home owner performing all the Nvork myself.
I
NOTE:plesc be aw a=Luz v J;]e bcc=µ wbo employ peso=Lo do r , c=—,=00 c MPQi + QrX on a d—a^C of
iGot M<X-I',--Lb—t 3r t in which Lt. mind-,Oc cc LS. i7p1ILC tb w LT DO( OL-=-&cd to be
c�vlaycs un-c Lbc--k&m ccz=p�ca Ace(GUI 52ss 1(5)�=ppliarioc by a bomcoa-acr fcr z kip-or t=mn may raid—Lc
lept n�tLu of as c=ployx under dzo Worhde Coazpomaiioa AeL
I
[usodcs:a.nd dsv.a Dopy oC tbia mi®off naay be foca nrded to tbo DcQarcmr�oa of IndauKricl Acodo.Iy otrioo or lraY+�foe Lb.
covczsc vciGc:aioo and t1=1 f_iha-c to Lcoim)oovc-aSc uo�socioa 25 A of l.(OL 152 m 1c d to the i�osifion of�•'i Pcc'wa
ooasiz of a Gx orup Lo 51X00.00 artdlor Orup to Doc yur=d civil P=..hia io 6c form or.Slop Work Ordc-,A
rrno 0(.'S 1 K.Do a day LF M:a me
For dcp.rta u. only
Permit Numt-S
h,
Signa i crrniucc e
SECTION,$-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: N.
License Number
Address Expiration Date
Signature Telephone
9 e >sere " rneierimeritContracto A `'° x Not Applicable [3
Company Name Registration N a—um��----
/v� l
Address , / ,(, Expiration Date c
G1 4/6 C.r'l a:./ l G L� Q1 /D - Telephone `��y�) 43 4't7� 7 0 C
SECTION 10-WORKERS'.COMPENSATION"INSURANCE AFFIDAVIT(M:GL.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...... ❑
'. �
11 om fl-Me fv—'M.!
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 Gable 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
r
I
SECTION 5 DESCRIPTION OF,PROPOSED'WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) F__J Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [ Siding[O] Other[�]
Brief Description of Proposed d 0 /
Work: G,fl�_e�l l Cpl p CG('
Alteration of existing bedroom Yes No Adding new bedroom Yes No 1
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
= ,n
66_ i i�ew�ouse n r�adtli
2 as to xtstii r tioustr>rg,comislQt�the=foll w� .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. 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.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 Ta-OWNER AUTHORIZATION TO,BE COMPLETED WHEN
OWN/�ERI AGENTOR CONTRACTOR APPUtES FOR BUILDING-PERMIT
I, An Ja u)e s a n W e7yi�c SQCt i(j G 2 ii fh(i as Owner of the subject
property
hereby authorize C
to act on my behalf,in all matters relative to 4ork autho ' ed by this building permit application.
c L-7 0
Signature of Own Date
D C as Owner/Authorized
Agent hereby declare that the state riffs 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. '
a
Print Name A% I
Signature of Owner/Agent JXJ V V Date
Section 4. ZONING All Informat-6h 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
1
Frontage
Setbacks Front id 54-6-01
Side L 3 C R: 0 L:=r t ' R:747-6
fb
Rear 419.9 6- !��
Building Height
Bldg.Square Footage I % !
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?
NO 0 DONT KNOW 0 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#1
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 0
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 ,- NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
t'
City of Northampton e
Building Department _
212 Main Street e
Room 100 �
r _
Northampton; MA 01060 s a
phone 413-587-1240 Fax 413-587-12721 t
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This section to be completed by office
W Map I_ot � Unit:
L,C'%h�
4/6^ � �� Zone Overlay bistrict
ElmStt'DlStrlat ., ; CBpistnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Pri Current Mailing Address: 6 10
h^rq r b�
Signature Telephone
SECTION'S: 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 V V l
3. Plumbing Building Permit Fee:
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) V Check Number--
This Section fvr Official`Use Only
Date
Building Permit Number. :Issued:
Signature: r
Building;Commissioner/Inspector of Buildings Date
File#BP-2005-1113
APPLICANT/CONTACT PERSON John Clapp
ADDRESS/PHONE 940 CHESTERFIELD RD FLORENCE (413)584-1703 Q
PROPERTY LOCATION 13 BIRCH LANE
MAP 36 PARCEL 209 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
BuildinjZ Permit Filled out
Fee Paid
T_ypeof Construction: CONSTRUCT 700 SO FT DECK 7 RESURFACE EXISTING DECK
New Construction
Non Structural interior renovations
Addition to Existiniz
Accessory Structure -
Building Plans Included•
Owner/Statement or License 024075
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9WATION 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 n
2oa
Signature of Bui ing 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.
13 BIRCH LANE BP-2005-1313
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map Block:36-209 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1313
Project# JS-2005-1762
Est. Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: John Clapp 024075
Lot Size(sq.ft.): 56192.40 Owner: SPANGENTHAL ERIC M&
Zoning: SR Applicant: John Clapp
AT. 13 BIRCH LANE
Applicant Address: Phone: Insurance:
P O BOX 561 (413) 584-1703-0
LEEDSMA01053 ISSUED ON.711105 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 700 SQ FT DECK & RESURFACE
EXISTING 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 Sisnature•
FeeType• Date Paid: Amount:
Building 7/1/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
13 BIRCH LANE BP-2005-1313
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36-209 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1313
Project# IS-2005-1762
Est. Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Clapp 024075
Lot Size(sa. 111 56192.40 Owner: SPANGENTHAL ERIC M&
Zoning: Si{ A"'-';!iCa lchn
AT. 13 BIRCH LANE
Applicant Address: Phone: Insurance:
P 0 BOX 561 (413)584-1703 0
LEEDSMA01053 ISSUED ON.711105 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 700 SQ FT DECK & RESURFACE
EXISTING 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:fA- �/�•O�
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 0
1
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAIMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc nature:
FeeType: Date Paid: Amount:
Building 7/1/05 0:00:00 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo