25C-035 (2) ¢SH�MA
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DEPARTMENT OF BUILDINIG INSPECTIONS f:
INSPECTOR '212 Main Street • Muuicipal Building '>o
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sup(:-,P .or. The stale defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a dne or"two fmi�_._.:
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-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 backfll),
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
Address of work
location
r
i
¢Tl1.A�fPT f..
O�
(riff Of 'Norfllailiptoli
g.. f - � g�c7axc31ntrll e' �_
i
p DEPART MEt-1T OP DUILDD,\G INSPECTIOtIS
I I -
212 Alain Strcet Municipal Building
I Northampton, ATass. OlOGO
WORCER'S CONCPENSATTON MSURA CE A F17MA-V-17'
--
vVILb a principal place of business/:esidence at: -- -- -
OlkiAte Acf. U(octU (/;hone') L(( —C(y
(sum/ci Iscalctap)
{ do hereby cerdi -, under che.pzint and penalties of perJurj, :hat
( ) I am an employer providing the following,%vorircr's coIDDCnS-rJop coverts for !m'
etuplovecs worlong on Oils job:
(Las -n=Comp=-,) (Poticcr Nt=mixr) — (T:-pinion Dom)
( ) I am a sole proprietor, general contiaaor or homeowner (c cie one) and hzve hired
[he coouaciors lined below wbo have the iobowiog woFket's compep_sauion pckles:
c 0 C0.,CMci0r) (In urancz Coinpany/1'oUC; }NluIIh'C) `1-2.1)1 juon Date)
j
(Na me of Contractor) (lnsaranec CompaativPOUM, tiumc_r) Date)
i -
(Name of Connaeta;) (Insuran(m Comran)-/PaUq- Number) (,._xpiradon Datc)
(2``ame of Cootractar) (Insurance Compai y/Pobcy Number) tr��uzoon Date).
I (aC,airl�.:oc31�cC.ilncccs.�_-y co inch iafor,�.-ioa pc�aiaiv�to.11 oocLO�) -. -_._ _--
'i
I am a sole proprietor and have no one woridng for me-
1 I a;it..a hose oN;rner performing all the work myself.
I, v
I NOT a-u tt,.
E:plcx be ac M]:JG l a wb0 Cspl fT-/ DC RCS IO do n cs c oo c tgair�+�orz oa.d..cll_Z of
as m«e 1), t'-o =r t in«$ic b kbc bocnoownc raid. or oa t1x VTmLod+I- %P tt�--^•-n L:-,ox oc=-c-cd to be
c2play=untie the Aa(GL152=1(5)1 a.pplia6oa by a bca=-ma re=G�_or pcmit=y c-rdcooc Lbc
leg.( of en e:.aloyoc under dto Wockoe,Coaxpomaiio AeL
I
I uod----d db-a oopy of this cat_cm_y be lorxncd.d to the GWar�t of]act+rssiJ nc+cdcc:Offiw oC 4a++r+oce far tbe
cov " vcTjezlioa A--,d Q t_t L-ih .r to.a.-tuc)Covcrao'e%MdC—103ica 25 A of MOL 152 raa Icd to the ixpoation of cricMIGA pcc&16=
co¢-i of fiat or up in S)l00.00:rtdfor D (-Lyp�y�o(up to ooc yc=:and a��l pm.tJC m 6c Corm ors S.op Word Ordc and a
Cuts of 5100.00 i day cp,i=trr_
permII t NUML-,—r
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i L7 P^
Sign.Zrirzt of Li crrnitIc:
SECTION 8-CONSTRUCTION SERVICES —71
8.1 Licensed Construction Su ervisor: Not Applicable El Name of License Holder: U pl()✓1"r N V
License Number
Address Expiration Date
Signs a Telephone
9Re°miste"r"ed'Iorire firi"caverriertoitFastoc " $' Not Applicable ❑
aJ actr �� L gJ3�S
Company Name I Registration Num--bey ---
19 0
Address Expiration Date
Telephone'•(/3 C(YF 3y�
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...... ❑
EU
N oil>�iQ >lie� g e.
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-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 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
F
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all;applicabie)
New House ❑ Addition ❑::; Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[O] Other ilk
Brief
Work:Description of Prop9sed ' I�� �� �J e� /1 I /ZI I
Alteration of existing bedroom Yes�_No Adding new bedroom / Yes —N.
Attached Narrative Renovating unfinished basement Yes �No
Plans Attached Roll -Sheet
,.6a_� �nr rrselc 6J E9 16 164 01,67 ,
:
a. Use of b0dinn•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
Masscheck Energy Compliance form attached?
g. Energy Conservation Compliance.
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 7a-OWNER AUTHORIZATION,-TO'BE COMPLETED WHEN
OWNE(((R'''SS AGENT OR GONTRAGTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize `�-��r. �C'v L
to a q�t rxtytbehalf,in all matters relative tow rk authorized by this building perTnit application.
JAI 14
Signatur' J-0&�e-e Date
Y as Owner thor
Agent hereby declare that th statements and information on the foregoing application are true and accurate,to the best o nowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Sign of Owner/Agent Date
' s
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:' R:- L: R.I
Rear
Building Height
Bldg.Square Footage %
3 1
Open Space Footage %
(Lot area minus bldg&paved
parking)
C
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
N0 0 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 0
IF YES: enter Book Page, w and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES Q
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 Q NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO Q
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 Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
MID
City of Nora ampton t � Eeran
e ; Building Department Gur Cam°
. �
- 212 Main Street
Room 100 a ter�IlAvatfa
- ?01%rthampton MA 01060 meets Stair" tafslari �' r
phone 413-587-1240 Fax 413-587-1272 PIoFstfeans _ �
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE'INFORMATION
1.1 Property Address: This section,to be Completedby office
S Ahapr Cot MUrttt
������ �-� Zone Overiarr:D�sfrret
EIm St D�stnct CB D�stnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) ,,- Current Mailing A ress:
Telephone
Signature ,
2.2 Authorized Aoent:
4eVArL� �OU2� Qq C��d-h2rr�t �rCl, �v� dGt� o(oYf�
Name(Print) Current Mailing Address
Si 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
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number t
This Sectlon-For Official Use Only
Date:
Building Permit Number Issued:
Signature:
Building.Commissioner/Inspector of Buildings- Date
WA
23 NORTHERN AVE BP-2006-0789
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-035 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0789
Project# JS-2006-1205
Est.Cost: $1750.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: HENRY J SOUZA 142895
Lot Size(sq.ft.): 5009.40 Owner: DENENFELD RENEE
Zoniniz:URB Applicant: HENRY J SO UZA
AT. 23 NORTHERN AVE
Applicant Address: Phone: Insurance:
24 OLD FERRY RD (413) 949-3431
HOLYOKEMA01040 ISSUED ON:21812006 0:00.00
TO PERFORM THE FOLLOWING WORK.-INSTALL 2ND & 3RD FLR PELLET STOVES
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 Sienature:
FeeType• Date Paid: Amount:
Building 2/8/2006 0:00:00 $25.002133
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
23 NORTHERN AVE BP-2006-0789
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV.-Block:25C-035 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Casa BUILDING PERMIT
Permit# BP-2006-0789
Proiect# JS-2006-1205
Est. Cost: $1750.00
Fee: 25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group HENRY J SOUZA 142895
Lot Size(sa. ft.): 5009.40 Owner. DENENFELD RENEE
Zoning:URB Applicant. HENRY J SO UZA
AT. 23 NORTHERN AVE
Applicant Address: Phone. Insurance:
24 OLD FERRY RD 413) 949-3431
HOLYOKEMA01040 ISSUED ON:21812006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 2ND & 3RD FLR PELLET STOVES
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: 0/K (S'V rc '
V
THIS PERMIT MAY BE REVOKED BY THE TY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. _
Certificate of Occupancy- S; nature: _
FeeType: Date Paid: Amount:
Building 2/8/2006 0:00:00 $25.002133
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo