25A-137 (4) 4(t1A7KP�.
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DEPARTMENT OF BUILDDtG INSPECTIONS
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INSPECTOR "212 Main Street 0 MUnlclpal 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 l:is/her construction sup '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 fami�- -
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
in de
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 r O
Address of work
location
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�Zx3sRcllnaclla' _
ca DEPARTMENT OP DUILDIJ\10 INSPECTIONS
212 Train Strcct 'Municipal Building
Northampton, Mass. 01060
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,I «'ORICkCIZ'S COi!OENSATION MSURANCF AllT'II)A.��iT
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(li cctu-x'Jperm�ttcc)
With a principal placc of buSiness/ csidence at:
(phoney')
(scr�.t/ci ty/sta.tc��p)
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do hereby cerdi --, under the p?jm and penalties of pcgury, tat
I
( ) I am an employer providing the followinu_ %vorkcr's cotnDcnsZ:Jo, cove-ge for Illy
etnplovecs wor'.Lang on tills job:
(Lnsuxan=CoEmam,) (Polio: tau.-aa=r) -- (�:pir�tior.Dai )
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( ) I am a sole proprietor, general concraaor or homeow-der (ci c:e one) and have hued
the coniractors listed below wbo hzve the follotviDQ worker's compen_sauon po.ticies:
('N'gMc of Conmiaor) (ln-uranc Cornoarl)yi'ouc; Numh-t ) D.-Itc)
I
(Name of Contractor) (Il swine, Comoanyipou \t mcsr) (L»irauon Date)
(Name of Cownc-io.) Olasurancc Compan)-/Pobq- M=bz.r) (ENpiration Date)
(Name of Coatmcior) (Insurance Company/Policy Numb:.r) (Expim6oa DaLe).
(aIIS �dIt;OC31 rh c,if ncc= --v W aKIUGt:imforMAEOn pc',•• to at1 OO=---[-O:7) .
O I am'a sole proprietor and have no one worL-ing for me.
I { j I am..a home owner performing all the work- myself.
JT NOTE:plesc be aw uc o— uryo splay p,�=tjD L�a c=--.:ciao c rg3ir waric ca a d..ciLt of
i 6.Ot mode tl_n Ltxw tiff La ui.S the bomo,r,ec r=d-,OC cc Ub.V L dt I we C==--lv OL=-d-=cd to be
c:iiployes unec the.=k&--c=p=-,,en Aa(GLIt 52-=1(5)} :.pplianon by a bomcowva rer c bca.or pe=il r=y a-rd—tl:e
IcVJ et�'w of en c=playec under dto Wockcet Cocnpoa aLka AaL
I
[undc�zaad that.a copy of thu mtcm�may bo foe_,dad to the D.op,_d ar jn&u ;d Aced.&of —or l�+r'eooa for the
coves sc ve i[ratioo AM ttu Liltae to Lc==tcovmse isodc soctioo 25 A of MOL 152 Qa ta.d to the=pow60"of aiminst prn+ltic
comic of a Gx oru p to S 1,500.00 arNcc orup to ooc yc3r and viva pm P,io i.dS room of.Stop wort;ordc and a
r>m of:;100.00.d_y LpinA me
Foe u,e only -
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/1 l'GTIIIII NLLIDtKr
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SignaUlrc of Lia=ucclPc ttcc e
SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
J=tes#ece }lo a Sri rowemea �it $c#a
' Not Applicable ❑
Company Name Registration N—um 6 a—r "- -
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION'-INSURANCE"AFFIDAVIT(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...... ❑
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 faun
structures.A person who constructs more than one home in a two-vear 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 responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Yf6rneowner Signature
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SECTIONS--DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑; Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (0 Siding[0] Other[0]
rief Description of Proposed
Work: '5 C) '
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa if New°€house ni ZESt sting 6 uslnwc0r>Yi tet�the o Iawln t:
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
L 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 Ta-OWNER AUTHORIZATION-TO BE,COMPLETED WHEN
•OWNERS AGENT.OR CONTRACTOR APPLIES FOR BUILDING:PERMIT
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.
P int Name
Signature of Owner/Agent Date
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Section 4. ZONING All Informat-i6h 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
#of Parking Spaces
(volume�&Location)
A. Has a Special Perm it/Vuhancn/Fndi ever been issued for/on the site?
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NO 0 DON7KNOW 0 YES 0 �
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON7KNOW 0 YES
IF YES: enter Book Pege and/or Document
�� ��
B. Does the site contain a brook, body of water orwetlands? NO �~� DON7KNDVV �_� YES �~�
IF YES, has permit been nrneed to be obtained from the Conservation Commission?
-
Needs tmbeobtained /-%` Obtained ��^ Date\~�' ' �
C. Do any signs exist on the property ��V 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 ellx NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre oris it part ofa common plan
that will disturb over 1acre? YES K �
~_~
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
4
City of NortF ampton
i riding Department
n
I X12 Main Street e _ '
Room 100
q (�(;5 Nort ' pton; MA 01060
h4 413 51 1240 Fax 413-587-1272
M-„--°I ,
APPLICATION TO CONIiTRUC ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
.1 Property Address: This sectrOn to t o completed by office
Zone Overla�r District
C106C)
Elie Sf District' CBp�stnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
j ��� �C� �t,\�✓V`Name(Print)(Print) Current Mailing Address:
'M& Y3'�C)
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 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=0 +2+3+4+5) Check Number D
This Section ForOffcial'Use Only
. Date
Building Permit Number.` Issued:
Signature: r
Building Commissioner/Inspector of Buildings Date
File#BP-2005-1239
APPLICANT/CONTACT PERSON ERVIN ERINN R
ADDRESS/PHONE 20 GLENWOOD AVE NORTHAMPTON Q 586-5370 Q
PROPERTY LOCATION 20 GLENWOOD AVE
MAP 25A PARCEL 137 001 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 —
T_ypeof Construction: REPAIR DECK&REPLACE SCREENS W/WINDOWS
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 FO LOWING 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 Commiss'
12 -
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.
20 GLENWOOD AVE BP-2005-1239
GIS#: COMMONWEALTH OF MASSACHUSETTS
MM:Block:25A- 137 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1239
Project# JS-2005-1656
Est. Cost: $0.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq_ft.): 9844.56 Owner: ERVIN ERINN R
Zoning.URB Applicant: ERVIN ERINN R
AT. 20 GLENWOOD AVE
Applicant Address: Phone: Insurance:
20 GLENWOOD AVE O 586-5370 O
NORTHAMPTON MAO 1060 ISSUED ON.6114105 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR DECK & REPLACE SCREENS W/WINDOWS
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 Occupangy Signature:
FeeType• Date Paid: Amount:
Building 6/14/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo