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5i DEPARTMENT OF BUILDING; INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building S
Northampton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNM 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 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 buildinL 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, Sl�N1Al� 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 q / t o 6
Address of work
location S4 QieZMP3 -A,)>`
4�tvat�T
A ch nt r t l zl - s
a DEPnR i kfE1-rT OP BUIL 00\1C INSPPCTtor.'S
212 Alain Street Nfunicipal Building
Northampton, A1ass. 01060
w 0 1R'S C 0 NAM E^i S A xZ 0 N'' L`I S UR-,I'i�CT- A ITEM A VIFF
--
(li txnsxJperrn�ttcc)
%VILL a prZncipaI place of busioess/residence at:
6-9 Stwovtg A w Mfg- gbtcp (j:hone')14 3-S-P.51)14)
( citylstair12�p)
do hereby terrify, under thc.pa_ins and pen21Ities of perjury, :hat
( ) I _t-n an employer providing the followinL workers comncns2:ion cove^ge for env
employees «`orbng on ties job:
(Laniran= Coopam') (Potic:?:u_-airr) — (r;-piraion DzL.)
( ) I am a sole proprietor, general contractor or homeow-Der (c cie one) amd have hirea
the concraciors listed below wbo hive the foilo ing worker's co�aerLc2don policies:
(i+'1IDe Of Co:=c-,or) (Insuranc c CoinO1y]}'yilouci Ntt1IILGr) (-E>:Jiiduon Datc)
(Name of CoD raetof) Olnsarane; Comoam-/?otie-; Nuncrr) (Expiration Date)
(Name Of Coarracno,) (Insurance Compa.o}•/PoUq- N;imbzr) (Expimaoo Date)
(Na-me of Cootraelor
(Innttanc-- ComrznylPoticy Numb,:-r) OExpirtion Date)
(ntradi:dai;;a5.1 r3ca.irnccc.ci�•w cicu�iaforcu�on pertciains to c11�-�..o�) j
r
{ ) I am a sole proprietor and have no one woridng for me. t
I am,a home owner performing all the work myself.
NOTE:plesc be ea-zrc ri— bcc.,m,--bo crriploy per o=w d;rx -, ec--.-.=00 c MPQ-v�odc CO L d..e1L2Z of
arc mote th M LIM— is«3ich the bcmcowvc raid=or oa the gvuD6 zpp,rtca:=tbees t r ax C."ay c,-=d--cd in be
eisploye-i uncle ttx-=k; -c==P ,.,;oa Act(G LI 52-1(5)�:ppli=6c,u by a bomeoQaa fer c 6c=---a permn r=y c-idm the
IcIP1=eau of——Ployer under tern wortdc Coaa9no3ctioa AeL
[un6c2wd th-a Dopy ortbii=i—w may ba for-�.nrded to tba[? nmca orin�Yricl n,-d—&Offo0 or Ina-vwoo for th,
oaYa�-Sc rciresioo,>_-id tlu f1J�•e to sxiuc bov��t�,s��25 A of T.{QL!52 an Icd w tlx i�sioa ar aimias!pea-11iio
000-ismg of.fiat of up to S 1 SOO.00 and/or mz�a-isoamc�i of up to Doc yc3r end o ti•il prncltio in tSc form ore Slop Wort Orc{c cod
fim of S 100.00 1 d_y can Mr-
oriry
Pcrm.it Numb--T
Si of Li crmiucc 1 o e b I"fzP" —- Lot
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
* "� Not Applicable ❑
ZOOMS
9 Re'aister"ed FlorrreramprovemenGnnfiractor,-
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10=WORKERS'COMPENSATION INSURANCE.AFFIDAVLT'(WG.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...... ❑
Sul
XI
; .
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 buildine 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 onsibility for compliance with the State Building Code,City of
Northampton Ordinances,State a aws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-:DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition Replacement Windows Alterations) Roofing
Or Doors M
Accessory Bldg. ❑ Demolition ❑ New Signs [C]] Decks [N Siding [a] Other[5]
Brief Description of Proposed ,�/ �
Work:_oo;r V- + ftT Tu /lf
Alteration of existing bedroom Yes�_No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes _�No
Plans Attached Roll �She�
sa:(;>. e�`rhisea,' �o�d` it�ron -exlst��nc '�o.�nct ca �ey�: _ �[Lmtn�rF�:
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
7SECTION'7"WNER.AUTH0RIZATION TO-BE GOMPLETED WHEN:
O.WNERS':AGEN`7"OR CONTRAC70RAPPLIES FOR:BU(LQ.ING PERIVfIt
I, ZAK aiww* 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 a4pen ies of perjury.
Print Na
Il Of;
Signature of Owner ant 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
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved FE-
#of Parking Spaces
(volume&Location)
A. Has Special Perm it/Varienoe/Fi riding ever been issuodJor/on the site?
11CZ71 �� ��
NO \�� DON7KNOVV \~� YES �~�
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry ofDeeds?
NO K � DON'T KNOW YES��
IF YES: enter Book | ) Page and/or Dnnument#| >
��
B. Does the site contain a brook, body oy water orvvet|unds? NO f(\) DON7KNOVV �~� YES \~�
IF YES, has a permit been or need tobe obtained from the Conservation Commission?
Needs toheobtained �~� Obi v~� Date
�^� �_� ' �
��
C. Do any signs exist on the propa�y? YES v_� NO
IF YES, describe size, type and location: (
D. Are there any proposed changes to or additions of signs intended for the property? YES NO 0
IF YES, describe size, type and location:
E Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre orioit part nfo common plan
that will disturb over 1acre? YES NO �yD
|F YES,then a Northampton Storm Water Management Permit from the DPW iurequired.
4 Departmenuee only a y,'
City of Northampton SftusoPerm, M . ",
Building Department WW
212 Main Street
Room 100 a� Ell�a�a t
Northampton, MA 01060 etoi3� ��'
phone 413-587-1240 Fax 413-587-1272 ,
t t#aerpe Ell
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE]NFORMATION
Tfi,ssect[onstabe completed byuffice
3
1.1 Property Address:
J�['I 5I{6eMA►J r4v�. Mapx� r #Lot � -�t1n,t
si YI1° E wi .6k 1
> f $ S y w'
Zone ! rid arm.,-� Ouerla�D�strrcfi
SECTION.2-PROPERTY OWNERSHIP/AUTHORIZED AGENT`
2.1 Owner of Record:
Na (Print) Current Mailing Address:
40. Sal - 971M
Telephone
Signatur
2.2 Authorized Aoent: '
Name(Print) Current Mailing Address:
-Signature Telephone
SECTION 3ESTIMATED.CONSTRUCTION°COSTS
Estimated
Item Cost(Dollars)to be Official Use Only
completed b -perm it-applicant
1. Building �2 cvocl�) (a),,Building-Permit"Fee
2. Electrical �.(b),Estimated<Total Cost of
1500 �Constructiowfrorn)(6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This.Section For Official Use-Onl
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2007-0529
APPLICANT/CONTACT PERSON CRAIG SAMUEL W
ADDRESS/PHONE 54 SHERMAN AVE NORTHAMPTON (413)537-5719 Q
PROPERTY LOCATION 54 SHERMAN AVE
MAP 25A PARCEL 113 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 18 X 15 DECK W/HOT TUB
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,RMATION 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 Commission
4--ic _,9 /� !7 v�
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.
t
54 SHERMAN AVE BP-2007-0529
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A- 113 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-2007-0529
Project# JS-2007-000771
Est. Cost: $2500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10715.76 Owner: CRAIG SAMUEL W
Zoning:URB Applicant. CRAIG SAMUEL W
AT. 54 SHERMAN AVE
Applicant Address: Phone: Insurance:
54 SHERMAN AVE (413) 537-5719 O
NORTHAMPTONMA01060 ISSUED ON:1112012006 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 18 X 15 DECK W/HOT TUB
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 11/17/2006 0:00:00 $50.00MO
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo