25A-129 (3) �855At�1i8[tt5 -
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DEPARTMENT OF BUILDI7,,TG INSPECTIONS /=
INSPECTOR 212 Main Street • MunicirW Building '>a
Northampton,MA 01060
y
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/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-t voJanu y -
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 Wilding department for the City of Northampton wants any person(s)who-seek-t-o
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 r'.egulations. 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 roueb buildinz 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 occupanev
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
L understand the above.
(Home owner/resident's signature requesting exemption)
I wiii call to scheduie aii required buiiding inspections necessary 10r Lilt: uuiiuing PC'"'it
issued-to me
Date-
Address of work
location
of �,Tciri U11133 toil
4 E j1i3tRCllat[110
4. o DEPARTME7-)- OF DUILD0,1C INSPPLi1ONS
212 Alain Strcct Municipal D1111d;n0
j •a
Northampton, Mass. 01060
I
WORICLIZ'S CONITENSA77O.N MSURA-NCE l'I� AVIT
(li ccnsxlperm�ttcc)
v-11th a principal place of businessfresidence at: "
i
G (.;hone=) I' 14" 33
i
I do hereby certify, under the.pzins and penalties of per3ury, hal
I am an employer providing dic following %vorkcr's colnocnsaUon cove Ige for Illy
employees wor�ong on ties job:
I
(Lsur---m= Conr.:z) (Polie_: Nu_abcr) -- (r;pirtior.Due}
I
i
'i ( ) I am a sole propricror, general contractor or homeowner (circ;e one) aid hzve hired
the coaaactors Iised below vgbo have the following worker's cot pep_sabon policies:
i
i
i
(NaMC Oi CO:IC^CiOT) (InR!ranc:: Cornpan)-Pi o6c N'tlf b-c-) tl-'71rd::Qi' O11c)
I -
— (Name of Concacor) (UIS- rancz Comoan`vpolie}• Nunlc_r) (–Ei-pir"6on Date)
I - -
(Name of Co=-aao;): Omsuranc-- Comp2n)•/Po6cy N;unb:r) (Expim600 Dale)
(Name of Contractor) (Insutaa� Comraay/Policy Numbs) (E pitatioa Dart).
(atlacb-,93aI-Eoc51>3c�.ifa•,-•,-ti-to mc!ucJz�afonn,..loo P n inimz to.I1 -
i
I am a sole proprietor and have no one worldng for me.
( ) I am,a home owner perform--ng all the work mysei£
NOTE:pl=-c be cwr Lrt ti.•-w1ji.hcmcoKVcn wta employ pc-s.om to do n= c=--oc c rc,xu wank of
i not mote ih--a Lti T---tints is the bomoa-mcr rtmda cc oa the pmuo6 zppa tca:r=tbcen L:r we�^� J1y—6=d to be
c=ployt=-s uad.-the I-c ; cc----,,=^,00 An(GUI 52-=1(5)).=pplicL6=by.bommo-=fm c 6c-------or pcmit r=y--d—tbc
Icsa!cl-� or.a eeployx under tho wockelc coo=pamatioa A-C(-
I
I uadC-C�tha a Dopy orthis chat my be for ard.d to tha Daps.nmma Om of l -ur+aoc for th.
j - cov—1 c veiratioo s d Qt_I ED=to tc=n tovmse=6--srf.1ioo 25A of bIOL 151 m I=A to the i-=,Z,, ioa ttf cimi=1 PC-, is
coasisiag of.fiat of up w S 1300.00.%dfor tiazFciaoat orup to Doc Y, mod.mod ci,_U pewltio is t5c focm of.S p work Ordc. d a
fim of S 100.00 t d_y tpi=a t>x
lror � J use only -'-"
pC('a1t1 NttIDt)CS
jAa PV --
Lot°.
Si of Li.=5 Pcrmiu= e
SECTION 8-CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not AAppplicableQ 13 Name of License Holder: Acce�r\ U y�✓` �/y�� V
License Number
'Po x 4►3, �t �. sa l,e1� ' C-1—t�5�•cv�; i4 `7-A-)-cob
A r Expiration Date
w� 4i3--fib-3 3 44- - cc 11
Sig a ure Telephone
JRes>fei �omen•rerinn atn = Not Applicable ❑
Company Name Registration Num er -—__.__
`Qb �, x�AS3 lukk-, Cis-*f�eO CaAl,-•, q - Zco('7
Address Expiration Date
mil! Y13-�t47-333yCul
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G:L.c.152 §25C(6))
Workers Compensation Insurance affidavit ust be completed and submitted with this application.Failure to provide this affidavit will result
in the denial of the issuance of the buildi 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 Awwaated, you may be 114b1e f r 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
r
SECTION 5—DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑: Replacement Windows Alterations) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [r-1] Decks [[] Siding[0) Other[E i
Brief Description of Proposed
W
ork:_�C'�ti l� Q X.S iron. �et� „ rr75 T ' t �.� r� e k ' 0^ ?N15VXV_%J�sQl('C�� b&iN
Alteration of existing bedroom Yes v�No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
t AfF vw rse�riid o acl #ioOf o c>s-in busing-F-1 orrratetewt a cilfor�uina:
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. fioodplain Yes 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
SECTION Ta-OWNER AUTHORIZATION="TO BECOMPLETED WHEN
OWNERS-AGENTORCONTi.ZA 6'APPLIES'FQR Bt)ILDING.PERMIT
1, 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
Zo i^ ,as Owner uthod
g2 hereby declare that the statements and information on the foregoing application are true and accurate,to the best o m w edg e
an belief.
Signed under the pai.s and penalties of perjury.
\ ` r
Print Name p�
Signature of O ner/Agent Date
Section 4. ZONING All Informati6n 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 ' ` ''-N'"
Frontage '
Setbacks Front
Side L:'1 I= R: 'L: R:i
Rear C
Building Height
Bldg.Square Footage
0110
i
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces ^- T—
Fill:
(volume I&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0,, YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 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 Q 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: _ 7�
E. Will the construction activity disturb(clearing,gradin ,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ,. NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r Departrnentusefln6y
City of Northampton tatua�Pe �' ti
Building Department Crray�P� � j A
212 Main Street
Room 100
a, 2 0 J J'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
1.1 Property Address: r�;,�. '� � r, This section,to be cafnpleted b�oi#`ice
p vT Zone O�erpyv°D' strtct
{
°.�'
SECTION 2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: C , 1
Name(Print) Current Mailing A res
�l I Telephone
Signatu
2.2 Au horized Agent:
Lk
Name(Prin Current Mailing Address:
r1U 4l3 -4 -33� ��� 913-)_5-1-33 3`1 -(Ce i I
Signatur Telephone
SECTION 3-ESTIMATED.CONSTRUCTION COSTS`=
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building /"Q0 0),Building,Permit Fee
2. Electrical -{b)Estimated Total Cost-of
iA _Construction from 6
3. Plumbing AJ Building Permit Fee
4. Iviecnanicai(rivAG) ���
5. Fire Protection
6. Total=(1 +2+3+4+5) VDO
Check Number !�
This Section For'Ofticial Use Only
Date,
Building Permit Number Issued:
Signature:
i
Building Commissioner/lnspectorof'Buildings Date
File#BP-2006-0960
APPLICANT/CONTACT PERSON JOSEPH DUNN
ADDRESS/PHONE PO BOX 413 GOSHEN (413)268-3383
PROPERTY LOCATION 69 DAY AVE
MAP 25A PARCEL 129 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid
Typeof Construction: REPLACE 2 ORCH FOOTINGS&REPLACE DECK BOARDS
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License 088718
3 sets of Plans/Plot Plan
THE FotLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
1 ATION 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 Co ssion
L 2 200
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.
BP-2006-0960
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
TV
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2006-0960
Project# JS-2006-1433
Est. Cost: $1500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH DUNN 088718
Lot Size(sq. ft.): 18992.16 Owner: FINN JOAN B&KIM F GOGGINS&
Zoniniz:URB Applicant: JOSEPH DUNN
AT: 69 DAY AVE
Applicant Address: Phone: Insurance:
PO BOX 413 (41 3) 268-3383
GOSHENMA01032 ISSUED ON:312312006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE 2 PORCH FOOTINGS & REPLACE
DECK BOARDS
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 3/23/2006 0:00:00 $50.001302
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
69 DAY AVE BP-2006-0960
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block: 25A- 129 CITY OF NORTHAMPTON
Lot: -001
Perrnit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2006-0960
Project# JS-2006-1433
Est. Cost: $1500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOSEPH DUNN 088718
Lot Size(sq. ft.): 18992.16 Owner: FINN JOAN B&KIM F GOGGINS&
Zomn7:URB Applicant: JOSEPH DUNN
_4T- ,a D A A.VF
Applicant Address: Phone: Insurance:
PO BOX 413 (413) 268-3383
GOSHENMA01032 ISSUED ON:312312006 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE 2 PORCH FOOTING' ° °C11 ArF
DECK BOARDS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET w
Inspector of Plumbing Inspector of Wiring D.P.W. Buiiding Inspector co
Underground: Service: Meter: ° J
Footings: LU
� Z
Rough: Rough: House# Foundation: o
Driveway Final: a ~
1 10
E U
M LLI 0
Final: Final: ° CL
Rough Frame: � o � � \
T
z M
Gas: Fire Department Fireplace/Chimp v
� o
Rough: Oil: Insulation: m a
a
Final: Smoke: Final: 6a{ 0Lj/g(i
4'
THIS PERMIT MAY BE REVOKED BY THE C TY OF NORTHAMPTON UPON
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Si nature:
FeeType: Date Paid: Amount:
Building 3/23/2006 0:00:00 $50.001302
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo