25C-011 e
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s� DEPARTMENT OF BUILDDIG INSPECTIONS �
INSPECTOR 212 Main Street • Municipd Building '
Northampton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNIR 108.3.4 to
act as l:is/her construction super-,ei sor. T he state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or twd-amz 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 bull mg 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 f 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 your), 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
L 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 rye.
Date
Address of work
location
' • OA�tLN}l p�O r.. / o�
2awrllntrt16. -- --
�-� DEPARTMEArr OP DUILDr1,G lNSPEC7FO1.'S
j 212 Main Strcet ' Municipal Dudding
Northampton, Mass. 01060
W RI�T-IIZ'S COYLPENSA'nO.N MSURA�CE AFFU),, ,vr'.
-
%Vith a principal place of businesslresidencc- at -
X3 3 SA4t SA-,s Atf- 5YF�e� (phoney' 75
(s�.t/ci tylsza.tc�a p)
do hereby certify, under dic.paim and penalties of pcg-ury, _h:i
j ( I am an employer providing die follo"Ving-11-111orkCr5 comDCns:�:jon coverage for Im
empioyces ��orlong on ties job:
I
G w C a7 32-0 1 s10 l
(In_nL72=Connate,) (Pcuc-: Nt=azd>cr) F xpirarior.D21--)
( ) I am a sole proprictor, general contractor or homeowner (c tie one) and have hired
Lhe coat actors list below wbo have the 50llolvio2 worker's coLoen_sation pokles:
i
I
(L;=C Oi C0n!7Z!C-,Or) (In urancc Cotnpan-y i'cuc,' D.ILC)
i
I
(Namc of Conezaor} (Insurance Comp aw?oue; \.-ujm Date)
(Name of Contracld:) (Insurance Compao}•/Pour- Nusbu) (Expir.:don Dalc)
l
(Name of Conaactor) (Insuranct Compauyy/Poucy Numb/:.r) ttxpiruon DalL).
(atIa.31:djs�ocal�ca.,Ia..+-. •�.co uiforaL:ioa pcwaias to a
i
O I am-a sale proprietor and have no one working for me.
I
( } I am.a home owner performing all the tivork myself.
NOTE:Plesc lx ctrNL t4,.-Lzjc bemcawacrs wto ca3Ploy pc om to rya c- - c=_=Qa ar rapaa�ork on.d%,T-u=o of
any more tl:a t`�cc=ict is%�sch the bomoo+�o¢road-.oc oa the pm or! z,�pv c�ea��tbce o ei ax C==_Uy oc=:d.--cd m be
e�loye s tad the..ui cs~x�'.--'gym Aa(GU!I52-=1(5)).zppGcaaw by a bomcoa-oa fe a Gam-a mimic a_y e.-id=o=tL,c
lc�a3 cu.as<of a.a-:Ployer under d.=Work e.Coeap•m.-tion A-c- '
i
I vnd�-rt�.aa dza a oopy a tbi.m�m.y 1x roa-a�urdae cn the D.opn,tmocG n�dcls'OT,-or 4av-for t6.
K-tif ctioa aad th:z Liltac to sxutt tavcrxCc tax',--=C ioa 23 A of kioL 157 eaa icd to the i=Polaioa of eimins!Pc- xW=
ooazc►ag of a fiat ortp to S I,S00.00 at,dfor ix�c-.xt orup to o=y-,_r tad ci ii pcoxi-ja is t5c form ora Stop Word:Ordc aad a
rl=of 5100.00 a&y&PI=pX =
PCrMit Numba-
S 1 IIk7ture of Lic�_sc:-JP rm i c t r� Ce � I A
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
RegistraWn`.137572
Exp�X2110/2006
Type: U8t!
KC CONSTRUCTION .
KEVIN COLBY
883 ST JAMES AVE
SPRINGFIELD,MA 01104
Adminis�ator
y
k�ibl of-.P'l r.t T OF BUILDI;`G IN8PEC7r?QNS
l�SF�CTC�l '}� `isiiaSleet • MaiticiTalPttildii,��
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HOME OWNER EXEM PTION ACKNOWLEDGEMENT
The State of'Mass ac t,.;Ietts ,dlows the. homeowner the right under 790CW 108 1.4 to --�
',ct a s sup :.-C,. l''. sta,.e dti,fin:s"Hoi-nE))owneI' as, ` P,'i'son(s)
u ho owns a parcel on which he,, the resides or intends to be, a one or rwo family I
I dwelling, att ached or dc-ached structures accessory to such use and,'or farm structures. A I
( person who constructs nlorc than cane acme in a two-year period shall not be considered a
home owner."
he building for the City of Noi thampton wants any perscn(s) who seek to
use,he home owner excrr pion, to act as their own construction suparvisor, to be aware.
triat b., doing. so you become responsible for compliance with state building codes
and regulations. The inspection pro.css requires that the building department be caller'
to inspect work at varici,s stases, whi t, include foundation/footings(before backf ll),
sarrotrllre holes (lrcfore prat rte` a rough building inspection (before work is
concealed),insulation inspecticn (if rectuired) and a final building inspection. The
building depat-merit requires Thos, Inspections before the work is concealed, failure to
secure these inwectiom can result in failure to obtain a certificate of occunanev
until the wort:can be inspe.Ctef4.
If tilt.' ho T_eovvner hirys -)-,neT JErfbrrr (electrical, plurnbinu& gas' the
1;omeo�r;r tirili be r sYC,l ib. :a r ,.k e care that the trades hired ecure their pro, r
petst7its ir1 :,cirtSuncticib t rte ,..uain�g permit iss�red. and that they get their required
inspections. Faii?.r-. v,&'-ica.:.i t:-ades t i secure the permits ant inspections as
required can DE AY tite proic,-t until such time as the prori r x errnits and inspections are
made
1. understand the abov,,
(Home owner iresident's signature requesting exemption)
1 will call to >ehcdule all re.uuired building inspectik)ns riecess'a7y for the buddinz Pei n-A
issued to me
Datt
Address cf work
lc.,cat ion
Qt3St6( stn i?I ^OW
R
SECTION 5 DESCRIPTION OF PROPOSED WORK(check alt applicable)
New House F--] Addition ❑; Replacement Windows Alteration(s) ❑ Roofing
Or Doors E]
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[[3]
Brief Description of Proposed
Work: -
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
saR f 'New hogse a�cl iit da i, teem 44-fi n- comp h i[caWt�q:
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
SECTIORTa-OWNER AUTHORIZATION,-TOuBECOMPLETED WHEN
OWNERS AGENT OR CONT.RACTOR'APP LIE S FOR BUIL"DKG: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. '
Print Name
Signature of Owner/Agent Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: hJl,
License Number
Address Expiration Date 2� (qW-2 q 6 -7
ignature Telephone
,,
0 isfe�e&146nr tiri'ra eitien ii >r Not Applicable ❑
Company Name Registration -um er - -- —
Address / 1i a0/
n Date
E
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...... ❑
1
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
r
IgULON 6-2gSCRIPTION OF EROPQ,X I'kJ'G,f l hoc k a Cable
Additi L
New Hnuse itlo" Alterationsl Roofing i
or Doors
Accessory Bldg. rL.-I Domolitior, how Signs �C2� Decks fG Siding(Cl', Other r*_i?
Br,ef 5as�r of Propq��ed
A1,6rat cr,cf existing bed--oorr ye5 Yes
Attached NwTatwq kenzvatrng in'lli sl?ec basernent Ves N r)
Manz Atta,-,Iad Ro;i -Sheet
5a.If Now house a6d air-aLd�itibb
b. Nwnber of rooms in each family unit:. Nurnhar of Pati"rooi*ns_________._.,_
6, P-oposedSquare footage of nPx Crv'.'uct!:,n- D0npnsijns____-_..
e Numhpofstunes"___
y. Energy Con.vip vaton Corn'11,3r3CF heck
Type G°GOr?S'YUGti`Zn
i t.3 cons mct or within I'L0 %,of yes N'•. constrixitcr,wit'nin,I cc yr. f?or"(1-Aair, Yes No
1. Uepth o;basemen!or;a,jar I-ade
i, ,V14 t)ukiling wf ifcrri,,o the S,:!D;rq Yes N,,)
1. Seo,,tc Tank P,;va"e ktc;' Ci"','water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN II
OWNERS AGENT OR CONTRACTOR APPLIES F DR BUILDING PERMIT
83 Owner of the&LbjRrl
property
hereby authonze �t!G�rS 0(
to art on�mttohhall ,in ail f 0 building permit apF,?ic;3tior.
siggla Cf Owner Date
owne r Auth iced ed
Acmt herebvde31are,that the statements 2nc f!f,rmabv,oi the forego app]�7a!kjn are tree and accurate,to crest of my knowledge
Si,pned undo"the pains arc' rienalties nf;)er,r.ry
Prir:t No
Sig- are o_fOwner'Agert D
C 01
e'S -GO SO 1;,1
Section 4, ZONING A4 Infcrmatco- Must Be Completed ce,m t Car Be Cenied Due Tr.Incorrp!ete infarrration
Fxisting Pr<,pesed Required by Zoning
T`rs coiLmn to be Giled in ty
Building D:pd:rrem
Lo:Size
Frontage .. _._.. _ ... ...... _.
Setbacks Front
Side i• R L'_ R
Building H,;ight
Bldg Ze Fr>atage % -
Open Space Feet& °o
a
s1e'area Trimt<F.tdc&payed '
4 of Parking Spaces
A. Fins 8 Special Pa,-r-A.'Variance/Finding a er been ,Ssued for%on the Site?
NC 0 C)C^#'T KNOW YFS Q
IF YES, date issued:
IF YES: Was the permit reco%)iid at the Registry of Deeds?
N0 ® DON`-r KNOW �} YES
IF YFS: erter Book Page! and/or Document ff
B Dees the site ccntai^n bronk cor!v of n.ater ar wat ands? NO cr DONT KNOW Q f S C,
IF YES, :ias u permit been cr ne=A to be(jbtained from tale Conservation Commission?
Needs to be obta 4wd o Obtained Date Issued:
C. Do ary signs exit on the praperty'? YES 0 NO �'ar
IF YES, c;ascribe afzr: type anc location;
D. Are there ar�y pr:�pose t,Cr additions of signs intendad for the property YES 0 fic
IF YES, describe site, type and iora_ion; _ ..__. ..
E. UJill the constructon activity disturb iclearing,grading,excavation,or fliln;,over 1 acre or Is t part of a rommm plaa
tha'rvil#dirt zrb over i a,re' YEi NO
IF YES,Cher a Nor;hamptcn Stul-1 Mater Manaaemert Permit from the DPW is required.
0 'd was :60 SO bT AOH
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JA(3a7ttT iltzff0''d"
v v Of f4orthampto.)
r 1t'f� 41 nPr1Jf Ri°rlt
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Iz6c m 1�10
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,a
1 Otlt ��r�3C�tzrl, lr4A01i'f;0 .......... j
pncne 41-3-W-1"401 Fax 413-5$7.-1272 P'ct5ite P9a,�;
I
� -- -- -- ---- --- � '1-— - t
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO hAMLY C)VVELLING
i SECTION 1-SITE INFORMATION
.�__—..This sactlon to be comzleted by office —
1.1 Prooperrry Andress'
Map_ 2—j� Lot (3 mil___
z one U Q Ovorlay District
Eim St.District CB District___.__.-_-_
SECTION 2-PROPERTY OWN ERSHVAUTHORIPED AGENT^
2.1 Owner of Record:
i rv� ,a -int) i:,irn_m•Fi7g lin„,�r7c'-vss
S' .atcr:
2.2 Authorized Agent:
I
Cuirent Madin3 Awass.
siynaturo Tcicohcret: !`�-p��
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item F-0imatad t,oct:nollnrs)to he _Isa C'nly
com 1 tp ec^by permit applicant W
�— ng , (a)t3uiidtng PermiteEa
1. t3Liia; ti�U � ZS
2. Eloctr!cal (b)Estimotod Total Cost of
Construction from u 1 '2,4v '
1 Plumbing Building Permit Fee
a Mpnhenicnt rHVACi a
5.Fire Prey-e fion
S. Total-(1 - 2+s+4+5) o Check Numt er [ 3
This Section For Official Use Only
Building Pormil Number: Date
---------------__---___-___ ------ issued:
I
i
j Euiding ConurnsaloneilL7s,rzcmr of Buildings
I 'd QTS faU SU trT noW
File#BP-2006-0582
APPLICANT/CONTACT PERSON KC Construction
ADDRESS/PHONE 893 St. James Ave. SPRINGFIELD (413)885-5860
PROPERTY LOCATION 164 NORTH ST
MAP 25C PARCEL 011 001 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 2.5.°o :a l 8 13
Typeof Construction: Reroof
New Construction
Non Structural interior renovations
Addition to Existing
Accesses 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
INFORMATION 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
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.
164 NORTH ST BP-2006-0582
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV.Block:25C-011 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:roofing BUILDING PERMIT
Permit# BP-2006-0582
Project# JS-2006-0855
Est. Cost: $11200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin KC Construction
Lot Size(sq. ft.): 13895.64 Owner: FENTON JOHN ROBERT&JOAN A
Zoning:URB Applicant: KC Construction
AT. 164 NORTH ST
Applicant Address: Phone: Insurance:
893 St. James Ave. (413) 885-5860
SPRINGFIELDMA01104 ISSUED ON.1112812005 0.00:00
TO PERFORM THE FOLLOWING WORK:Reroof
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 Siiinature:
FeeType: Date Paid: Amount:
Building 11/28/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo