25A-113 (3) I N6_
�I►iAMP�
Qlztp of Wort4ainpton z
�1HSSACt�itBltt4 �
DEPARTMENT OF BUILDW 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 78OCMR 108.3.4 to
act as his/her construction supc.r,"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 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 i/cz,to*
Address of work
location 5+ 5RC-R x,%1
Noa,VMAM fryP+ MA- COW
.)...- V.
� 6 �i�asaartlnsrtll'
r llEPfiRTME1T7' OP £+UILDOI G INSPECTIONS
212 Alain Street ' Municipal Duil(ling
Northampton, Mass. 01060 '
W0 RICE R'S COMTENI SAT'ION INSURANCE AFM)AVIT
N:11th a principal place. of busiress/re:; denc I:
_?g'._= Q/�L±!`►�_yE�.ju��T--Kt�o►?�_L1�t1 0[0�-�2----(ph: nc =}Y�3-S_ 3z_-SZLg
do hei-6by CCrt1I5`, 1117;'ci- die p Ir1S Cana pCrl?itICS Oi pCfjm-y illiil-
I am an employer providirl- the i0l)o`,ViIlf_ '•VOI'r_CrS C01111c"Isarloi] GOVCIa C -or II1)'
eri]ployces working on this job:
(Las- ramc. Compam') (Pc c;Nttrnfxr) --- (ra. .iI-,:tion Dzre) -
j I a1J1 a sole proprietor, Central c:cnr(a`or one) and t:avc Hill d
the contractors listed beiow.,"o l . c
ori: L: ers coy penor1 oic.es:
'N=c of Corumcm o;} a ce Conn-:] ',T
(Ins _,.n Giicf Ntlin)vr) ( y, o- Date)
(Name of Connctor) �a,lv/Pe!icr 'N'trntr--r) 0--Ypir :ion Dare)
(Name of Coninctor) insl-r]c^ c - ,`...^^_--.
.. � _,:ii;' ii'oL•c, Nulntxr) Es; '.�:.._ Date)
- (Name of Cant-actor) - (It1S I 1I1C Come.y:y Polier Numb--r) (F;:r,: ::io Date)
l 1 ani it ,]Ole 1)I Ol?Ilett?i cii11 11 Ell vc i?O OIl l;r�
—M:,3 101 i i .am t? h011ie OWI1Cr
not tztete th_n throe ur_i+s i:te-Lic'i t.!ic I•.;,-1�;'.lzr-rc::;:��c;a;::<.:�.•-.._,z urtcr_.^.f LhGC:o c:2 n�{CCrsalty cc<::::::::�:c
c^'.al0y 3 U-ti�? . _ 152
legal ctatuc of an o=ployx un u, t::n Wcviccra Co--=, ition:`.ci
1 uncle stand tha cm,y of t}i+rut-l-,=mAy bo faw,v r J to tl o IYt a tzrs of It dustriel A,,& z&Cif c of for tlx
cov4a�c va-mcm-tioc and that L-ilurc to sz;.r 25A of?.IGl.152 an Icad to tlx iazr�sitiat c;c i 1 pctsl:a
comuimg of a rtnc of Up to S I SOU.CYj n:t1'. Itr, x� :1 of::p to cr,.y... ..:.1 civil in do F(-,on of a Stc-p',Jeri
- FcX cSq%uvirltsS use crtty
SECTION 8 rrON,STRUCTION SERVICES
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Re sYere o"mmnrovernent C^n+�a�+^r W Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 1N9RKERS' COMPENSATION INSURANCE AFFIDAVIT(MG:L.-c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this ap.plication. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No...... ❑
6=1 ft e 1 � ail'
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"homeo,.vner"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 resDgdsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and La and State of Massachusetts General Laws Annotated.
Homeowner Signature
�.SEGTI N�5�D S°-R(P7slONt�PftOi?.0'SED;VIIQRK. checkra7l�a 'I.ii�a`ble�,�_ ��
..,'
New House ❑ Addition ❑ Replacement Windows Alteration(s),® Roofing *92
Or Doors 0
Accessory Bldg. ❑ Demolitionta New Signs [ ] Decks bZ] Siding Other [X]
Brief Description of Proposed Work: PLplAm- wl-id S5 J—o Ceder t;41!21
'�wke wF eld {+arv4 S}ePS wNd 614b:•, back. .(+►.,d,
Alteration of existing bedroom g _Yes No Adding new bedroom Yes >C No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll D• Sheet❑
a. fNewhou�se�andordditfontoexism housing�c'o-mple�e tFiefohlovu�:n
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?—{,,oK,y0"60 gie Fireplaces or Woodstoves wOt>0 Number of each
g. Energy Conservation Compliance. Mascheck 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
S�CT701�C� �OYIINERAII�HORIZATION TO BE COMPLETED WHEN
OWNERSAGENIO CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property
hereby authorize to ac.; on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I SAM C( l(� 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.
SAM
Print Name
Signature of Ow A ent Date
} L
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
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg.Square Footage %
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 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
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
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, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
�s This secRo>n t'6 b �oiriplete by
d� office
1.1 Property Address: f f ¢ w Y tx
Wi�
154- SH60MAM Xic- Ma .
f t
ND rZ'r ftA1�PTO N . AA 6\�o Zone �� Overla�r D�str�ct
h'�m�.D19trICt� ��, c� ney f yCBD�$tr1C:t�
SECTION 2-PROPERTY 6WNERSHIP/AUTHORIZED.AGENT
2.1 Owner of Record:
sqM CiZ f4Jt-, A)pOrAdA PruA),Mi4
Name(Print) Current Mailing Address:
. ym--531 9
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION'COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed bypermit applicant
1. Building y (a)'Building Permit Fee
2. Electrical (b);;Estimated Total cost Of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(NVAC) ,
5. Fire Protection �S
6. Total = (1 + 2+ 3 +4+ 5) s 1 s.�U -Check,Nu
This Seddon-For Official Use Only
Building Permit Number: 8Z Date Issued: Y cb0
Signature:
Building Commissioner/Inspector of Buildings Date
54 SHERMAN AVE BP-2004-0982
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A- 113 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2004-0982
Project# ]S-2004-0142
Est. Cost: $15000.00
Fee: $75.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10715.76 Owner: CRAIG SAM
Zoning:URB Applicant: CRAIG SAM
AT. 54 SHERMAN AVE
Applicant Address: Phone: Insurance:
54 SHERMAN AVE (413) 537-5719 0
NORTHAMPTON MAO 1060 ISSUED ON:4113104 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE WINDOWS, DOORS. CEDAR SIDING,
ROOF IN BACK, SHHETROCK GARAGE, TAKE OUT FRONT STEPS
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 4/13/04 0:00:00 103 $75.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo