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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municip d Building
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Northampton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her constriction SW.:".";sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a vne dr tivo fame 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 buil mg departmerit for the--City of Northampton wants anyperson(s)-whoseek to - -
use the home owner exemption, to act as their oven 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 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 me. _
Date-
Address of work
location
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DEPARTMENT OP 5UILDr,-,,C, INSpec7101,S -
j 212 Alain Street ' Municipal Building
Northampton, ATass. 01060
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WOR.IT-IRIS COI\IQ'I;NSATTON 13'�SURA.NCE ?.I'l),, .v r
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'� � �l ccns.^clperm�ttcc)
vk.zth a principal place of business/residence at: - -
g Cv?� t�f3
( ty/sta.tLfa p)
do hereby certify, under dic.pzint and penalties ofpeg-airy, €h i
( ) I am an employer providim- die foilowine'%vorkCr`5 comocnsabon cove ale for lnti
1 elnpiovccs ��orng on ties job:
(I=xr-amp Comr zv (Pone, N=mxr) -- (T :pirvor.D2=)
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( ) I am a sole proprietor, general contracor or homeowner (ci cie one) and have hired
t-he cone actors listed below vgbo have the following, workers comnep_sadon pckles:
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(N=c of Corr naor) Uri-uranc: Compan)'fl�GUc ,t ':71i,Ifj0n Datc)
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(Name of Coamaor) (Insura cz COmDanti'/po `umcer) (Lxo'L bon Daic)
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(Name of Con>;-aao:) (I>ZSUranc Comran}/PoL-q N isb�r) (Expirdon Daic)
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(N;-Ime of Conaaeior) (Insurance Comcary/Poiicy Numb r) (Expire don Dalr).
(aaac3 ad��oc�!nccct,irocc . to mc!u,A-rafor7ni'ioc P=-L�to.II we-tars)
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am-a sole prop netor and have no one woridng for me.
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( ) I am,z home owner perfon=g all the work myself.
NOTE:pl=.=be aorirC Chi +(<Je hem vc.,.�bo e¢ ,C),pcaos to do *, c=--�=oa c rc;.-ir-orx ca.d,--LL-;:of
cot men-t—Lbsv the bomoowvc reed.of oo the�oua6 s�pvzlea:l tbe-c'.n r_-c oa C=�r-Ry xcz d-zd to be
i eizploye s un4=the A={G Lil S2 t(5)} a,••pl cn.7eo by a bomeo,fe or permit=y c idco=Lbc
iIc-P1 ct.a_ui of ea 41oy.r under dh Wo(fr,cei co�oo A•e
[uadesz•.nd tb.e.a copy-k hi.catctaod m...y be foc-,-,d..d to the Dopertmma of Inda.snd n.odests'om-or Ors�n for tb.
cove L rcire2ioa and the C iltac to soauc Ear cryso tmdc sex-.,ion 23A of),101-137 ma led to tbo i=*OZaioa oreimics!pca 1w,=
comi=ng of L fiat orup to S 1-moo Lztdfor i:�srisoo�n or up w ooc yc xod citil pm.ltia in 6,roan or Slop Wort Ordc and a
rises of S 1 00.n0 L day L5,L�tDc
- .. For dcs.rta.':J u.c onJy
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SECTION 8-CONSTRUCTION;SERVICES t
8.1 licensed Construction Supervisor: Not Applicable ❑
Y� 11 C c-7
Name of License Holder: �✓�1ry► . �.J ^�C�?-�_. _ _ _ _ _ Ll 'J7 '7
I { License Number
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Address Expiration ate
Signature Telephone
9.Re�stered l me°tin rbvement Contra or �1 Not Applicable 0
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Company Name . Registration-um er
Address J Expirat- ibn Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANGE.AFFIDAVIT'(M.G;L.c.--16121§125C(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 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 Max 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
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SECTION 5 DESCRIPTION OF PROPOSED WORK(check'alhapplicable)
New House ❑ Addition ❑:. Replacement Windows Alteration(s) Roofing
Or Doors E3
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[[--3] Other[O]
Brief Description of Proposed
Work: C" f( ) wl� R_ r: CJ ►f' t
Alteration of existing bedroom Yes No Adding new bedroom_ Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
-, a a�^tc;, r'=,;.k � x��'={ J:"-q,rimai�:''y.,��-.A..;a.wi'^TM,-�.:s�"" a a�re.,p.,,.mss,-, .*'�..r�-•w. .-,r
fia [�Newkh'orrse�� iad r�c��ai��#c�exlsti>tc��o�sl >EC€,corop�et ��e`' aitQ�l�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
SECTION Ta OWNER AUTHORIZATION-TO BE-COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR=APPLIE&FOR BUILDING PERMIT
T) -as Owner of the subject
property
hereby authorize �Z
to act on my beh9lf, in all matters relative to work authorized by this building permit application.
A W7 L7
Signature of Owner Date
as Owner/Authorized
Agent hereby declare t at 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 Nam
f, . �L I;,?. C%`;_
Signature Owner/Agent Dat
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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
Side L– L R:=
Rear
Building Height --' -
Bldg.Square Footage i %
Open Space Footage % -
(Lot area minus bldg&paved i a
parking)
r--
#of Parking Spaces
Fill: i
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:'.
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book •.,.. Page and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO ( DONT KNOW 0 YES 0
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 0 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:
E. Will the construction activity disturb(clearing,grading,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.
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City of Northampton
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Building Department r ± e
212 Main Street we SeSk°� �
Room 100
Northampton; MA 01060ro= ens a�5truct€tral F'fart � _
phone 413-587-1240 Fax 413-587-1272 Pto�Sitns � � ,
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed=by offtd
1.1 Property Address:
NIaE Lot Unif
A11 ,
Ziine 'Overlay Distoct
4 , rh SE District CB Distfiet
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT`
2.1 Owner of Record:
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Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Ll` �l(\
Name(Print) Current Mailing Address:
t 3t13t
Sig'e a 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
D. CCC -r
2. Electrical (b)Estimated Total Cost of
-3 c Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection _
6. Total=0 +2+3+4+5) C)n 0 Check Number Q
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
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Building Commissioner/Inspector of Buildings Date
File#BP-2006-0656
APPLICANT/CONTACT PERSON HENRY J SOUZA
ADDRESS/PHONE 24 OLD FERRY RD HOLYOKE (413)949-3431
PROPERTY LOCATION 25 NORTHERN AVE
MAP 25C PARCEL 034 001 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: ADD 3RD FLR(2)BEDROOMS&FULL BATH _
New Construction
Non Structural interior renovations
Addition to Existing_
Accessory Structure
Building Plans Included:
Owner/Statement or License 087984
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 Commissio
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.
25 NORTHERN AVE BP-2006-0656
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-034 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:renovation BUILDING PERMIT
Permit# BP-2006-0656
Project# JS-2006-0968
Est. Cost: $33000.00
Fee: $125.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HENRY J SOUZA 087984
Lot Size(sq.ft.): 10018.80 Owner: DENENFELD RENEE
Zoning:URB Applicant: HENRY J SOUZA
AT. 25 NORTHERN AVE
Applicant Address: Phone: Insurance:
24 OLD FERRY RD (413) 949-3431
HOLYOKEMA01040 ISSUED ON:1211912005 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD 3RD FLR (2) BEDROOMS & FULL BATH
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 12/19/2005 0:00:00 $125.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
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25 NORTHERN AVE BP-2006-0656
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-034 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:renovation BUILDING PERMIT
Permit# BP-2006-0656
Project# JS-2006-0968
Est.Cost: $33000.00
Fee: $125.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HENRY J SOUZ_A_ 087984
Lot Size(sq. ft.): 10018.80 Owner:_ DENENFELD RENEE
Zoning:URB Applicant: HENRY" J SOUZA
AT: 25 NORTHERN AVE
Applicant Address: Phone: Insurance:
24 OLD FERRY RD (413) 949-3431
HOLYOKEMA01040 ISSUED ON:1211912005 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD 3RD FLR (2) BEDROOMS & FULL BATH
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: p
Final:6t--� L��1 Final•�S`pb "Y>" g
Rou h Frame:
fi 1-for
�Z /
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: ACA Insulation:G k -d
Final: Smoke: L Final: OK, Os�asl0 6 L,o(A(5
THIS PERMIT MAY BE REVOKED BY THE CIT OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate Of OCCLIpancy Signature:
Fee'Type• Date Paid: Amount:
Building 12/19/2005 0:00:00 $125.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo