31B-121 (5) j
�oo`E V 7 tIf �t11I�i�I1l�fD11 _
DEPARTMENT OP BUILDING INSPECrl01.'S
212 Alain Strcct Municipal Building
Northampton, A1ass. 01060
I
WoruQ,RIS COYTENSATIO.N GvSURAItCE AFFU)AVV1T
01 cc�perm;ucc)
sV1Lh a principal place of business residence at: --
(phone-')
j (srrr-_..tld ty/sZalt.�a p)
do hereby certify, under dic.pzinS and penalties of perJury, hat
( ) I am an employer providing the following'workes comoensadon cove age for u1y
employees worl3118 on tilis job:
I
I
0nnLr�=Conn:.,) (Pobc: NtL�ocr) Dzt^)
O I atn a sole proprietor, general coou-actor or homeowner(c cie one) and have hired
the contractors listed below wbo have the follocVinQ worker's ca�oen_t2tion pe!icies:
( ±amc o.Copt c.orl (Inn!rancr. Comoa, Pobc, ?,,U_Ml
i
(l lame of Cootraor) (1 L7dra.ncz Comoam`vpoUc \t r�crr) (Fi�irtion Date)
(_Name of Connaclo;) (lnsuranc Compan}/Pot)c}• N,urbcr) (Expiraoo Datc)
a -
(N;me of Contractor) (In_suranc-- Comcany/PoUcy Numb-:r) (E�pirtion Daft).
(a1—±1 zdu::ocsl dcd.tr ac ry•w aic?ud;iafocau:ioo pctdia:os to..It Dena-so:-s)
{ ) I
am 'a sole proprietor and bave no one worldng for me.
I am.a home owner performin g all the work myseif.
NOTE:ple3e be etrtrC t*,•kf Ie lxmeoµvcn vtip ploy dam t.o do�---;.-..-.,rkc) r—.-.:caao c rraair work on a d..c1t_�of
ant tuxc th a 4iu t�r� n u'si�the bomoownc rcnda or oa the pvuncy z�puitea r�tbean e r ox��rlty oars d--rcd to be
cixploycs"d the waS c's cczpc-- tioa Ar=t GUl S2 a 15
t ( )) :pplinDOO by a bomcoava fcr c lieu=or perm,r>_y c idcooc the
ie$aI rtaaie or ea cgloyec under dio Woeic-el Compe�A,
'',,, I uada'a.aad tha a copy orchLu eIIte m..y b.fec-wdod to the 0�9 m ortndixricl Aoadc=[Y Offioo orlmu+000 roe tb.
°OYCn� moo-_�d 0-L-iltac w scarrc"0--sa trade 7oQioa 23A of MGL 15-2 cn led to the impcmidoa of t-cimiw,pan Wi
--Lzau8 of a fine of up to S 1.300.00 a ace Drop to Doc ycr=d avz1 pcaaP•a in do form or.Stop Work Ordcr and a
fim or S 100.00.d:y amt m�
-----
For u.e only
'7 ry PcrmIt Numbcr -
/� Lot K
�.
S,Iatun of Licxsucc/Pcrm i ticc -
i
r..Crity of 'Northamptlan Z
. � �I 1A54ACltliSttt4
DEPARTMENT OF BUILDDNG INSPECTIONS /=
INSPECTOR '212 Main Street • Municipal 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 sups:: ,•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 famffy- _
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 fegulations. 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 Ina
C.Q L� S �1 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 '—'11 t � IDS
Address of work
location J, c v S
r
r ;Z�) t C)to 0
r z
SECTION 8'-CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
S ReaTstecem�lfmpro ieier► ont Not Applicable ❑
Company Name Registration Num er —--- ---
Address Expiration Date
Telephone
SECTION 10 WORKERS"COMPENSATION INSURANCE AFFIDAVIT'fM:G:L c.-152,;§25C(6)j.
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 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 ning Laws State of Massachusetts General Laws Annotated.
_ l
Homeowner Signature
I
SECTION 5-DESCRIPTION OF PROPOSED WORK(check allaaplicabte)
New House ❑ Addition Replacement Windows Alteration(s) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [C]] Decks [p Siding[p] Other[p]
Brief Description o Proposed
Work: t __ - _ � � 3,d
Alteration of existing bedroom Yes _No Adding new bedroom Yes x No
Attached Narrative Renovating unfinished basement Yes _ t No
Plans Attached Roll -Sheet
-� :
.
s _[ Ncw-0�ouseand�aadcicfiQn� aFex�n ausln ,.calrx>� tetethtQ In K
a. Use o ding:One Family 1/ Two Family Other
b. Number of rooms i ch family unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new const n. i_Dime ns
e. Number of stories? t
f. Method of heating?
t� �' Fir ces or Woodstoves 'fp,-JAr,t umber of each
g. Energy Conservation Compliance. Masscheck y Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. wetlands? Yes No. Is construction within 100 y. oodplain Yes ✓ No
j. Depth of basement cellar floor below finished grade
k. Will building nform to the Building and Zoning regulations? Yes No.
I. Septic nk City Sewer Private well City water Supply
SECTION Ta-OWNER`AUTHORIZAT[ON,-Td<BE"COMPLETED WI EN.
OWNERS AGENTOR`CONTRAC.TOR:APPLIES'FORBtJILDtNfG PERMIT
I, 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
I, 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 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
1 This column to be filled in by
Building Department
Lot size '
Frontage
Setbacks Front
—,
Side L R:- i 'L:- R:
Rear
Building Height
Bldg. Square Footage °/a
Open Space Footage % ```�
(Lot area minus bldg&paved
arkin
#of Parking Spaces
Fill: i (�
(volume,&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the s-Ite?
N0 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: j
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 O r NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City 6f Nora ampton
\6.
F Buildinb"l?epartment 4 w -
212 Ma Street
Room 100
IR
Northafxtpto A 01060
phort"I- b$ r 40 Fax 413-587-1272 CQ a
APPLICATION TO CONSTRUCT,ALTER,REPAIR ENOVAT R DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1.-SITE.INFORMATION
This`section to be compCeted lay ofece
1.1 Property Address:
/`) /.�[) Nla'� Lot UnFt.
V, Zone O�cerfayDistrrcf '
u s
r
SECTION Z-PROPERTY OWNERSHIP/AUTHORIZED AGENT';
2.1 Owner of Record:
iA
S �6
Name(Print Current Mailing Address:
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=(1 +2+3+4+5) Check Number C9'
This`Sectibn For OfficiahUse.Onl
.Date
Building Permit Number. tssued:-
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2005-1022
APPLICANT/CONTACT PERSON JACOBS TIMOTHY
ADDRESS/PHONE 5 EDWARDS SQUARE NORTHAMPTON (413)584-6076 Q
PROPERTY LOCATION 5 EDWARDS SQ
MAP 31 B PARCEL 121 001 ZONE URC
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: UPDATE KITCHEN&INSTALL CABINETS, SHEETROCK KITCHEN&3RD FLR
New Construction
Non Structural interior renovations
Addition to Existin¢
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 n
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.
5 EDWARDS SQ BP-2005-1022
GIS#: COMMONWEALTH OF MASSACHUSETTS
a :Block: 31B- 121 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1022
Project# JS-2005-1403
Est. Cost: $9500.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 3789.72 Owner: JACOBS TIMOTHY
Zoning.URC Applicant. JACOBS TIMOTHY
AT. 5 EDWARDS SO
Applicant Address: Phone: Insurance:
5 EDWARDS SQUARE (413) 584-6076 O
NORTHAMPTON MAO 1060 ISSUED ON:4126105 0:00:00
TO PERFORM THE FOLLOWING WORK.-UPDATE KITCHEN & INSTALL CABINETS,
SHEETROCK KITCHEN & 3RD FLR
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 4/26/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo