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g, DEPARTMENT OF BUILDIN G INSPECTIONS
INSPECTOR 212 Main Street * Municipal Building '
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as 1-1-is/her construction sup<�-,"i sor. T he 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
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
p 6 Fi��sexchnsrtls '
UEI11LRTME1.T' 01" £UILDDJ G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Klass. 01060
WORICER'S COMTENISA'MNI INSURANCE A. i MAVI.T
(1ic�r.._Jrcrmutc^)
v"if a a principal place of business/res dcnce
e�Z LL7 L E`5 I Ej4- o v-, XCI A D 011 rc d(/ done'=) �-f(_3-SP'6•_7 7U P
CIO hereby Ceri1IY. u"ICA !- dic• p2ir1S and pcll2ltles of
xI am an employer providing the iollo'..'iI?L '.:o:kcr's Goinpcns�.,-uon GoVer22,C for Illy
elIlployceS working on tills job:
-
a==c: Compam•) c-;cc:Nu:nixr) (Rxpimuon Date)
I an) a sole proprietor, rgentrai contmcror homcotiener (circle one) and 'gave hired
tli' cot�rlctra �o-r-s fisted beiov, ,-,to ii-J:, th]° :0 ::r:, '�� oFkPl'S compeIlS;-uon p^olic'.es-
oAkp tja L1>N(4�67��
(Name of ConLmctor) (Tn--u=nCC LvIP.^`."i'1:PGlICj NLLTT1LYi) iT}', .+. Cr: DatC)-
V� 5 PTV M 61 k�,_ g-tv,+ CJK. ywC 0 00 19 1 /0
(Name of Contr<ctor) (las-d-anc (E 71-atioa Date)
C) � SG p S
(Name of Contractor) Con] 2n.;(Polic; Pate)
(Name of Contactor) (ItuZ ranc Comm_--y/Policy Number) (Excl-16o-Date)
("tLlcb_6jit7GY:1!
I iLTl a SUIG l?rC)}?r1eCC)i 2:1'1 have no 011C ''•':'l';C�;iii'i�
I itl t? 110IZIC U�'+i1C'' iii C�I111Ii^ 1�1 i:. v5....,
?JOIr::pI=SZ Lac rwz:c tl:s:. ilc tx<-co zr-s ti o cap!.r ;r- ct . -':3czcc c .: r m cs:r a r c•;;c, _ cl!i-,c.
not crtOre t!z n thrroo ni+s in rr-<
c ploys u_ry'cr t1x wc;.mss cc x•,:_im/•r (GT,152-!:s1 5)),- a:by a hc.r:co%ncr:`or a licc_,c a P:r n::: -•.'tinrc ..
legal natuc of"cxploya under tLn wcvkcla Cop wz•.itioa?xi-
I uz�dc_-ztaad th+t a copy of(lii ctit=—cat ruy bo fcn—+ IaJ to t)»IY_Siartzxn:of lodzutrinl A4tv:�-:.x'0MI of for tax
coven gc vrrifictioo and tttt ft.iltuc to t uc my r-g urn .zctiM 25A of MG1,152 can lc--d to tlx irnr-> Sliion
Coc ' o ftrr of ttp to S l SOU.oJ n^'`or i :�riy c zti:�of::?to rr.:} r.:.i c vil xzultiu in d c'c rtn cf n S!r.,`;J z(}u�nrd n
CSIOO . iy
C) `(/ For Sq uuxr,tsl uic«ily l
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AtDAturc Jf'crm ittc.• _ - _......r.;_.�i •' -
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SECT.ON$FCONSTRUCTf.ON SERVICES
r
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Numb
KD4100 w ROA A P T(
ddress Expiration Date
i
Signature Telephone
ffRegs ere rn mo vement-. ont`racto Zilli 11 NEW,, Not Applicable
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 0 WORKERS' COMPENSA,TIQN INSURANCE AFFIDAVIT(M G:L. c. 152,§.25C(3))
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 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 acecptable 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
jj
SECTIOI �i�D S 440 FtPROPOSED WORK check.a�f a Ncable ` �"
New House ❑ Addition / Replacement Windows Alteration(s) ❑ Roofing ❑
/ Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: _ F1 q =(,}( [ r' 'rt'C� KlTco E to, TO L(V i If 6 9 CIC114
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet 0
-eaar =flux a :n orditronto.existinghousingcom`"ple�h-efoCowing
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? KCS L6
d. Proposed Square footage of new construction. 2 - S bimensions A 1-(D)( << ! ��� `61"6X IO R
e. Number of stories? G r J rr
f. Method of heating? F2' RL 0 p I 9= CL Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached? PG
h. Type of construction WOOO [ MC
i. is construction within.100 ft. of wetlands? Yes _ No.f Is construction within 100 yr. floodplain Yes X No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? _ Yes No
1. Septic Tank City Sewer Private well City water Supply _
SEC�OT� ' �, W ERAUTHORIZATION TO BE COMPLETED WHEN
�?VYfi4FfS E CONTRACTOR Af'Pl IES FOR BUILDISG PERM{?
1' P.0 ti PAM , as Owner of the subject property
hereby authorize RG 3 G/M PO 26-6 c--k to act on
my behalf, in all matters relative to work authorized by this building permit ap licati n.
2 ( 7
Signature of Owner Date
G A LO P-E 6 Gl2(C) 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 p ' s and penalties of perjury.
asignatof G(A �Ga GGO C)
Lner A gent ?- Date
i
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
2
Lot Size
,2-C
Frontage
Setbacks Front
Side L: Z 5 R: yO L: z R: 3Q Z
Rear �{UG �{C �
t
Building Height Z 2.8 /
Bldg. Square Footage S 70c) % ,5 cr -2!;
Open Space Footage 11 t % _ C�
(Lot area minus bldg&paved 1f G d "t q l s"S
parking) Y7
#of Parking Spaces
Fill: C)
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
I
s
NO X- _ DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
J
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 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. Are 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
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 "
APPLICATION TO CONSTRUCT,ALTER,Rk�,*R,-R'iNWWrE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
Tars„secha tame�ctple o#�rce
1.1 Property Address: A4 3 {
I M- P c�E QUA}Q
'!3~J ' 4 h fj dt A !Y 8
SECTION 2--PROPERTY bWNER5HIPI-AUTHORIZED AGENT
2.1 Owner of Record:
Roti- U) PAA-sc-H ( MAPLE P,106C k)iw1-0P H,4
Name(Print) Current Mailin Address:
Telephone
Signature
2.2 Authorized Agent:
me(Punt Current Mailing Address:
JU&Jkl
q( s- i� &G, 7 U c1
Signature Telephone
S CTION 3-E -ED"C STRUC ION`COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by rmit applicant
1. Building �r (a)`Bwlding;PermitFee
2. Electrical 2 (b)Estimated Total Cost of '��
Construction from. 6 h
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (I + 2 +3 +4+ 5) C� Check Number
This Section:For Ofrjdat.Use-Or!
Building Permit Number: PO`f' J Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-0734
APPLICANT/CONTACT PERSON Roy Giangregorio
ADDRESS/PHONE 82 COLES MEADOW RD NORTHAMPTON (413)586-7708
PROPERTY LOCATION 180 MAPLE RIDGE RD
MAP 36 PARCEL 270 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Pernut Filled out
Fee Paid '
T_yneof Construction: CONSTRUCT LIVING RM&KITCHEN ADDITION
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 062571
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO�IATION 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 Str et Commission
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.
e
180 MAPLE RIDGE RD BP-2004-0734
GIs#: COMMONWEALTH OF MASSACHUSETTS
MapBlock: 36-270 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0734
Project# IS-2004-1061
Est. Cost: $70000.00
Fee: $106.50 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Roy Giangregorio 062571
Lot Size(sa. ft.): 86248.80 Owner: PAASCH RONALD N
Zoning: SR Applicant: Roy Giangregorio
AT. 180 MAPLE RIDGE RD
Applicant Address: Phone: Insurance:
82 COLES MEADOW RD (413) 586-7708
Workers Compensation
NORTHAMPTON MAO 1060 ISSUED ON:1113104 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT LIVING RM & KITCHEN ADDITION
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 1/13/04 0:00:00 6294 $106.50
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
't City of Northampton
BUILDING INSPECTION LABEL
A P 1:30
Inspector
Dats � > > ��
1
180 MAPLE RIDGE RD BP-2004-0734
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-270 CITY OF NORTHAMPTON
Lot: -001
Permit: Bullding
Category: U IL N TPERMIT,
Permit# BP-2004-0734
Project# JS-2004-1061
Est. Cost: $70000.00
Fee: $106.50 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Roy Giangregorio 062571
Lot Size(sg. ft.): 86243.80 Owner: PAASCH RONALD N
Zoning: SR Applicant: Roy Giangregorio
AT. 180 MAPLE RIDGE RD
Applicant A�lcdress: Phone: Insurance:
82 COT ES MEADOW RD (413) 586-7708
Wokers Compensation
NORTHAMPTONMA01060 ISSUED ON:1113104 0:00:00
TO PERFORM THE FOLLOWING WORKCONSTRUCT LIVING RM 8t KITCHEN ADDITION
POST TIIIS 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:�/-(' f, _ �/✓� h
�,�? ``t Driveway Final:
Final: Final: f
11 Rough Frame:-
` j e �// :a�
....�''
Gas: Fire Department Fireplace/Chimney:
1
Rough: Oil: Insulation: 6 '( -5 )200 -
Final: Swoke: Final: e/,r c f-,7
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND RCC GULATIONS.
4esi Certificate of Occupancy —" -�'" gnature:
FeeType: Receipt N<.: Date Paid: Check No: Amount:
Building 1/13/04 0:00:00 6294 $106.50
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo