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.d, DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building '
Nortiiwnpton,MA 01060 5
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction sup,.:v,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 fatnr
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 r',egulations. 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 your), a rougb 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
mad
41 116
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I, understand the above.
( ome ow r id nt's ji r_equesting exemption)
I will cal schedule all required building inspections necessary for the building permit
issued to me.
Date
Addres of work
location
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„� e CI its Of Poril1zaut}itoll - _— —
a 11 itch n s;c(16•
o DEPARTMENT OP 3UILD0\10 INSPPG?)O1dS
212 Main Strcct ' "Kunicipal Duddinc.
Northampton, Mass. OIOGO
WORlCERIS COiATENSA-MN MSUR CF AITFMA. r1-I'
I, 111 _ 14
(ti�xlpermi ttcc)
with a principal place of business residence at: -- ---
Ac�is xUvre-r-a r r2kKs � . C 3
FLOrzqiye4- AA . 0 11?46 2— (l none::`) tSF 4 � C4")
T (sutxtic�ty/staLcr>j p)
do hereby cerdi -, under tic-pains a.nd penalties of penury:, :hat
( ) I am an employer providing the followinL w oricer's comoeasa�Jo;: cove age for Illy
etuptovcc:s worL2iig on this job.
(La,u an=Comrz-r v) (Pclic:?vu-ter) -- (E:•pirtion Dom)
`( I am a alE: prot7r,etor general contraaor or homeowner (c c:e orle) and have bused
t-he cosuaCprS listed below vybo hzve the follo%ving workers comps-as-a ion po.kles,
(t`+amc of Co^_:aaor) (InRralloc COlnpan),iTPGUCi ?�` =<:) �_S7i,d�OC Daic)
-- (Name of Cogczaor) — (lnszuauce ComoanviTolic- Numn--r) (%x-o uon Date)
(Name of Coaaactoc) (laa aac:Company JPcUq- Namber) (Expiradou Datc)
(Name of Couaactor) (Insurance Company[Policy Numbs) (Espi ziioa Date).
(aWC']zddi�oc�1 bcG.if acccz,_-l•to aucud=iarcr 0C p=-t�to.1J cc�•-,.c.o:s)
I am a sale proprietor and have no one woridDg for me.
( ) I am,a home owner performing all the work` myself.
NOTE:plesc tx evrarc Lt._-;„_]c hcc=,O+.�vtio e[=play pczom to eiO �s,:e�ao c rcpair-uric oa.d,.c.tti=g of
OAt M—tb---U,S—mie's La t jiLC1 tb. r¢fd,.OC Oa Ib4 VJ Ct CJ ZPP I�tt, C- LT 0,<C.*Z--UV OCCr:a--rcj W CY
eaeplar—ur,2—the. Jkct ca=p---••m Att(GUI 5L= ap U=Ltioa try a doe=%-za fer a Gc�_cc pemh=zy c idmrc tL-c
ic�a!cU.txc of e.a=Ploy-under di.Worf_ols C.oaapoc—Lisa Act_
l-vZ—,.ad dJ A a copy of this—d r y bo f_-__,j d to tbo pcgartmcct of In&+x+id Aoadcat7'OTI—of l,—r-c LO
oovazsc v' iGe ioa Dad lIt_t L•h M to"==)covmse under soc oo 23A of h((3L 131 can tt^d to the i�—of rsimiuA paultio
coasi.:-rag of a(roc or up to 51}00.00 artdror irpri3oam4t of up to 0z-r.:r t.ad civil panYio is tSC form of a stop Work Ord--acid a
frm of S 100.00 a d:y .Pla-g me
,. For f�.r't:z>✓-il u.c ody
perID71 Numbcr
Lot
Si Date :
-
SECTION 8-CONSTRUCTION SERVICES +
8.1 Licensed Construction Supervisor: 62045 Not Applicable ❑
Name of License Holder: 41,E14— *E/1 � ��� 3 / 2
ZOP-FAA-wl")Q� F"An2-t44s 0>� License Number
Address Expiration Date
Signatur6 Telephone
9.Re$^ stefed Ho 6iiii6iArg i 4in 66a y' v1 _ Not Applicable ❑
L) Al.- 14a&4L sre-k-b — /-3Z! -0& z
Company Name Registration um er
¢d 8' L)C7 R-T74- l�Al2-44-S
Address Expirat Date '
rLU Q,Kk C�� ( r YJ Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVlT'(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...... ❑
v
Wig-
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 OF PROPOSED WORK(check'all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) EJ Roofing ❑
Or Doors 0
Accessory Bldg Demolition ❑ New Signs [p] Decks [Q Siding [0] Other[pj
Brief Description of Proposed �^
Work: '7 f( Z. (3 C A P S 2-t-? i 7 Q e Sj W+4 L
Alteration of existing bedroom__Yes No Adding new bedroom Yes Nom/.
Attached Narrative Renovating unfinished basement Yes X No
Plans Attached Roll -Sheet -Y-
sa If-New-hoase artid a�a�dEtio�to�eztstiiTC�•6o�tsrlcr Comgfet�th��fffQUViria•
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. 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 CONT CT OR APPLIES FOR`BUILD1NG PERMIT
as Owner of the subject
property
c
hereby authorize
to act on my a alf,in all matters relati to ork authorized by this building permit applicati .
/ ,4 6 ;-1V
Sign re of Owner Date
1, f)E f L a(7 A4 S.T-L-?A 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.
O e f L K U YN s7-a—n
Print Name S
Sign tore of Own /Agent Date
Section 4. ZONING All Information Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
n Building�Department
Lot Size C✓ 7 S' �l C- (L I
Frontage
Setbacks Front
Side L: R: 'L:7; Rj'.�'
Rear
Building Height
i
Z Z -- _
Bldg.Square Footage ;%u� 3 i % y
Open Space Footage % �---�
(Lot area minus bldg&paved L-
parking)
#of Parking Spaces
Fill: 1
(volume,&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ( DON'T KNOW Q YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW 0 YES 0
IF YES: enter Book Page, and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 Q NO
F
IF YES, describe size, type and location: j
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
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 Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Vol
City of Northampton _
Building Department
212 Main Street
Room 100 r el �rarta� � �
Northampton; MA 01060 etas o�5tKtict�u�'�su
phone 4113-587-1240 Fax 413-587-1272 �"pP't1it�?lan
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This c n to beicompletedbynff�ce
1.1 Property Address: ^,t r
8� �, L untt
W A Overlay District
CRuistnct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
�r}I,"ice £ 1-(e LLY I F�Kt 5 ? CLdI,t,Yl e!?8 e 2 LAi
Name(Print) CugAnt Mailing Address-
Telephone ¢
Signature ' s =�
2.2 Authorized Agent: V ii� p Cp M F�ff21w S 7
Name nnt) Current Mailing Address:`C
Sig tore 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
3. -S CO Construction from 6
3. Plumbing — Building,Permit fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) �{ 5 _5 C� Check Number
This Section Fdr Official Use Only
Building ermit Number. � � Date
g � �' Issued:
Signature: !^
i
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0316
APPLICANT/CONTACT PERSON NEIL HOMSTEAD
ADDRESS/PHONE 408 NORTH FARMS RD FLORENCE (413)584-0458
PROPERTY LOCATION 52 WINTERBERRY LANE
MAP 36 PARCEL 227 001 ZONE !J F,
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: CONSTRU T 26 X 34 GARAGE W/2ND FLR STORAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 031249
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN 6RMATION PRESENTED:
JJ 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
444-1�
Signature of Build' g OfficiA 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.
52 WINTgRBgRRy LANE BP-2005-0316
GIS#: COMMONWEALTH OF MASSACHUSETTS
Max-,Bl :36-227 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0316
Project# JS-2005-0414
Est. Cost: $45500.00
Fee: $132.60 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: NEIL HOMSTEAD 031249
Lot Size(ss . ft.): 60984.00 Owner: RIFKIN SHELLY L&SHELLY L&
Zoning: SR Applicant. NEIL HOMSTEAD
AT. 52 WINTERBERRY LANE
Applicant Address: Phone: Insurance:
408 NORTH FARMS RD (413) 584-0458
FLORENCEMA01062-4513 ISSUED ON:9121104 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 26 X 34 GARAGE W/2ND FLR
STORAGE
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• Receipt No: Date Paid: Check No: Amount:
Building 9/21/04 0:00:00 1210 $132.60
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
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52 WINTERBERRY LANE BP-2005-0316
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-227 CITY,OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permits BuiidLng DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A)
GateQOr�:
BUILDING PERMIT
Permit# W--200-93
Prgiect# ]S-2005 0A14
Est.Cost:$45500:00
Fee:$132.60 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: NEIL HOMSTEAD 031249
Lot Sized sa.tom: h 4$ .00 Owner: RIFKIN$Haj.,YI. &SHELLY L&
_ _ tmlFr1
_ _ D
X LA
Anuticant Address: Phone: Insurance:
408 N(,3,�t.TH FARM AD (413) 584-04f 8
FLORENCEMA0106-451 ISSUED 0 N:9121104 0:00:00
TO1"ERFOJ T1WtP ALLOWING WORK.-CONSTRUCT 26 X 34 GARAGE W/2ND FLR
STORAGE
POST THIS CARD SO IT 1§VI, SIDLE FROM THE STREET
Inspector of Plumbing inspector of Wiring D.P.W. .. Building Inspector
Underground: Service: Meter;
Footings:
Rough: Rough: ' i t �--44,$�7- House# Foundation:
Driveway Final:
Final: Final: f /��
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough:
Final: Smoke: Final: Pic ri -;?1.0:5
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATION ,
'fj f n _ Si nature•
FeeTyb : Receipt No: Date Paid: Check No: _ Amount_
Building 9/21/04 0:00:00 1210 $13 2.50
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo