25A-115 (2) LEI ity of 'Wart4amptan
�TtlA54AChII8tff8 -
DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR '212 Main Street • Municipal Building
Northampton, MA 01060 .
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction supc: .•isor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fanu'ty — _--
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 fegulations. 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, / ,/ ti --a' understand the above.
(Home owner res' ent'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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arfl 13111 tots _- —
g f 3c3axcfinsctIa' - —
w d DEPARTMENT OP BUILD0\1C INSP2CriO1.'S -
212 Alain Strcct ' Muoicipal Duilding
Northampton, Mass. OIOGO
%VORICI:R'S COMPENSATION MSURA-NCE AFFIDAVIT'
-- (];ccvsxlpcnn)ltcc)
%,,,ith a p pal place of businessfresiden.ce at: ---- -----
— (phoney'}
(su�t/ci t`J/stalLl�p)
do hereby certify, under d.ic pa-.ins and penalties of pegury, h:l
( ) I am an employer providing the followimz worker's cotnocnsabop cove.--,;c Lor m)
etuplovees worlang on tills job:
OMSU-r-an=Conracy) (Polic:Nu-mixr) --' (r:-piston Da--)
O I am a sole proprieror, general contractor or homeowner (CiTcie one) and have hired
the contractors listed below who have the folio%V*Mg worker's comoensaiaion policies:
(i anic 0; Co0'-:acwr) On uranc Coinpan)'/PObci Namh---) F`Dlnjuon D'itc)
(Nzmc of Coolrzcior) (Insuraac;. C.omoa2v1po!ic; Date)
I
(Name of Coaa-aeto;) (insuranc: C.ompan}•/Polk}• N:tsber) (Expir=doo Date)
I
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(Name of Coaractor) (Insurance Comrzny/PoUcy Numb:r) (Expi-.6oa Datc).
(acuG1+ �di�oczl bca,ifacccszr�•w a�c?v�•infortma..tioa pc.-teinias to.11
{ ) I am a sole proprietor and have no one workdng for me.
I am.a home o-,vaer performing all the work` myself.
I�
1 NOTE:plc be ewzrc rfi,.wl�Je hemrrnvocn w�Cpl ay p,,,=to d� cs-t�ao c rgau Wori;(a.d,-11^Z of
ant mote tl—Um——,r is ttict ttx bomw ort wide c,oa the noun`,z7puten_.rt tbeao u- ax C=):Xy oc,=- rod to be
ertpioyea urec the--i=m c==p�oa Ate(GL'15Z.=l(S)�:-ppti=6cu by a bomma-=fm c lie -=or permit r>_y C%16=«the
legs!cta7ac of ea czpioyer under dao Woricce,coo�yooa.t Act.
I uadezzaod tha x copy of rbi.m�my be fc—wded to the peputmevt of l—i,—id dead=%:'Office or ta3u+oen for 16.
covcr 4bc�rCtioe and th_t L-iltae to soarrc'eoverasc=der 10e Oa 23A of htOL 151 m Ied m the impmuioa of tsimiazl peoilric
000siaing or a tine arup to s I.300.00.rtdfo imprtsoom of up to oac yc-.r=d Civu pmatja is 6r form ora Stop Work.Ordc Lad a
rim or S 100-00 a d--y LpdnSt me
[For dcp —LI u or7
crm t `um bC7
P_-- mot .
ignaturc of Lic=L-ccfPcrrniucc —G�e
SECTION S-CONSTRUCTION SERVICES 71
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
'R@Q15terQOIE1l7A @RteElxOEtrB `uH s :. s :a
Not Applicable ❑
Company Name Registration 1-um er - — --
Address Expiration Date
Telephone
SECTION 10-<WORKERS'COMPENSATION7NSURANCE AFFIDAVir M.G:L.c:152,§25C(fi))
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 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) ❑ Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[O] Other[[3]
ief Description of Proposed
Work: K%PG. L� GQ(3/.JE�7S ���L�67leolk K1-7c,0EAJ
Alteration of existing bedroom Yes Adding new bedroom Yes ✓No
Attached Narrative Renovating unfinished basement Yes o
Plans Attached Roll -Sheet
a_ItevtotSe ano dLQexciasl ..COrIg "e �ECi fca �t1q:
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 AGENTORCONTRACTOR.APPLIESFOR 6UIILDIN6PERMIT
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
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 Na e s
ignature of Owner/Agent Date
" ~
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Section 4. ZONING All Informatibn Must Be Completed. Permit Can Be Denied Due To Incomplete Information
4 Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved i
#of Parking Spaces
^
A. Has a Special Pennit/Variunce/Findi issued
'
NO 0 DON 7KNOV 0 YES 0 ^
'
IF YES, date issued::
IF YES: Was the permit recorded utthe Registry of Deeds?
NO v���
� DONrr u/vvvv 0 ,co
IF YES: enter Book i Page: and/or Douument#
'
�� ��
B. Does the site contain a brook, body or water orwetlands? NO v���� DON7KNOVV �~� YES v��
IF YES, has permit been or need to be obtained from the Conservation Commission?
`
Needs tnbeobta.oed �~� ��to�ned �~\ Oate [yaua�'
v�� «_� . �
C. Do any signs exist on the proparty �� ��� YES «~� NO v��
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 o[a common plan
that will disturb over 1 acre? YES K > NO ~_'K l
|F YES,then a Northampton Storm Water Management Permit from the DPW iorequired.
- wit Northampton '
c
tltlr akn Department a
21in Street
Q5 100 e
��N 2 TVorth ' pto ;AMA 01060trr �
- phone 413-58124 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1.-SITE=INFORMATION-
Thjs sectron to be completed[�yoffice
41 Property Address:
sH �?/�' vN[ap Lot tyrttt
�Zarie Oyerla�Distrrc�
r.. •. CBVD�.sfrrcf `
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED.AGENT
2.1 Owner of Record: _
Name(Print) ? Current Mailing Address: ,+ //3 3 c o i _'1 ! 2 J V
Al Ll'lc � L�� ✓ Telephone `f yC l
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
.SECTION 1-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 C ' -'/
This Section For Official Use Only
Date;
Building Permit Number. Issued:
Signature:
i
Building Commissionedinspector of Buildings Date
File#BP-2005-1294
APPLICANT/CONTACT PERSON WHITE GERALDINE F
ADDRESS/PHONE 32 SHERMAN AVE NORTHAMPTON (413)320-2134 Q
PROPERTY LOCATION 32 SHERMAN AVE
MAP 25A PARCEL 115 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid 3,7Z2 .5a
Typeof Construction: REPLACE CABINETS&SHEETROCK KITCHEN
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 C ssion
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.
32 SHERMAN AVE BP-2005-1294
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A- 115 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1294
Proiect# IS-2005-1727
Est.Cost: $6600.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 9278.28 Owner: WHITE GERALDINE F
Zoning:URB Applicant: WHITE GERALDINE F
AT. 32 SHERMAN AVE
Applicant Address: Phone: Insurance:
32 SHERMAN AVE (413) 320-2134 O
NORTHAMPTON MAO 1060 ISSUED ON:6/24/05 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE CABINETS & SHEETROCK KITCHEN
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 Sienature:
FeeType• Date Paid: Amount:
Building 6/24/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
32 SHERMAN AVE BP-2005-1294
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A- 115 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1294
Proiect# 35-2005-1727
Est.Cost: $6600.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sy. ft.): 9278.28 Owner: WHITE GERALDINE F
Zoning: URB Applicant: WHITE GERAL.DINE F
j T- 32 9-1E !'1'AI LIE
Applicant Address: Phone: Insurance:
32 SHERMAN AVE (413) 320-2134 O
NORTHAMPTON MAO 1060 ISSUED ON.6124105 0:00:00
TO PERFORM THE FOLLOWING WORK:REPLACE CABINETS & SHEETROCK Kh-CHEN
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: �Ci'��f��<�� � � Final: , t ! w
� � i �t•,...`�`�,%j- Rough Frame
Gas: Fire Department Fireplace/Chimney:
Rough: Oil:
Insulation:
(•��'
Smoke: Final:
Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy
Signature:
eeType• Date I':�i^:: Arnouut:
Building 6/24/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo