25C-055 O¢�tU►AlP�o
city of Wart4amptan
�1 I�T1i asSA[}'1[StiI9
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR
212 Main Street • Municipal Building
NorthanPuni, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNM 108.3.4 to
act as iris/her construction sup,e: ,• sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
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 regulations. 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. I -
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=:
�0 Q-�'C�2,.�T�y
a E GI of Norf1ja111�1f011 _ _
43 Inch nrcf1s."
' C DEPARTMEI17 OP BUIL.Di>\'C INSPECr101.'S ;
212 Main Strcet hfunicipal Building
' Northampton, Mass. 01060
I
WORIaWS CO'NIPENSA'nON MSURANCF Al=, AV1T
j .�►✓e-
C�j
i (li crns.^rJpc-tTi1i ticx}
v.,I th a pri"Icipa] place of business/residence at:
i l
�in f yh,4 p/auz (phone=`) /7 �� 7✓7�
1 (Sar._.ilci tylsta].zf�p)
do hereby ce ', under the P?.irS and penalties of pc r J `; :hat
j -
( ) I am an employer providing die fol]owing worker's eomocnscbon cove 2ge or 11'
emplovecs working on this job:
(imauan= Compacy) (Polio: Ku_-zACr) --- (r:-pir`iion Dam)
O I am a sole proprietor, geoeral contractor or homeow-Der (c cie one) and have hired
,l
the c000-actors Gsted below wbo hzve the `olio%ving worker's comnensadon policies:
i
(amc Ot Conrrnao;) (In-urallct Colnpan)'IPOuci bale)
(Name of Conmaor) (1n7dr-anec Comoa.ny/Po!iei Numin-_r) (ii- Lmijoa Date)
(Name of Coan-acio,) (Lasuranc: Compare)-/PoUq- Numbu) (Exairadoo Daic)
(Name of Contractor) gmsuraace Cocpcaay/Policy Number) (Etpirauon Date).
(aIIsG�: i�ocaJ cSca.if ncxx4-•to a,c!ud;infoc-m,=oo pCtai,aio�to.1t
{
XI am a sole proprietor and have no one woFk-ing for me-.
( ) I a.m.a home owner performing aU the%vork myself.
NOTE:pies be aw tit it*•wt ]e bc,=,c even uj employ pc ions w L, -• 0= cax'.:e,00 r revs woric on.d%• U_,-;,of
ont moot lh_n tune—,r is wt&:b the bomaow'ner rcxide or oa the Q-ou zpp uua_r1 LbW_c r_-c one C-.a:,Uy oocid=-rd w be
�xplaycz unr c the- ir_t'a 0=:p�oa Act(GL152s=1(5))�apvlia000 by a bomooava fey c Gem.cc permit n_y e.id:aoc the
i
IegU cL:iu of aA e=gloyer under d,o Workxeg C.o¢*amalioa Ace-
1.±>'4- d tha a oopy of thil ait®erri m.y bo for-,.ended tv rho Dcgorta,ma or lnd.srr d Ac d_&Off oa of 4x�for tho
oovc4sc veriremioa and ttu C ittnt to sire� =tnJdrr section 25 A of h{OL 152 an led to the imxsII3oa of eimiasl pcnallia
comisi�of a fine of up to S 1_�00.00 Iridfor im{y-iyon�or up to ane year end eivu peo4tie in be roan of a Stop Wart Ordr and I
rim of 5100,00.d_y 4pinp tree
For dcy.rts-.�1 u+c only
lea-7 ��P.__ tot R
s, `fie J `
of Li�sr_..1pct-tn-iucc _.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su�perviissor: / Not Applicable ❑
Name of License Holder: (f '`�ic O /f
License Number
Address Expiration Date
_ . /d ` 7
Signature Telephone
J� estereiffame roaeme�if Font acs ti ' Not Applicable -❑
N✓! `7 G/1✓I of �i/�f!✓�c G/�w✓C✓(i+G t -<-/! ' /��
411 Z
Company Name Registration Number
Address / Expiration Date
Telephoned//7 z/./ 71:7
SECTION 10-WORKERS'COMPENSATION"INSURANCE AFFIDAVIT(M.GL.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...... ❑
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 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 Ivlachusetts 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 /v/�
f
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [[31 Decks [ Siding[0] Other[ol
Brief Description_of Proposed
Work: �Ztj�il:✓ .CX/il--I, I
Alteration of existing bedroom Yes y No Adding new bedroom Yes ✓No
Attached Narrative Renovating unfinished basement Yes L,- No
Plans Attached Roll -Sheet
�".m.. °aa •sx.q `� .-,
sa ew hoa a an i cl+ ror #a;exlsfirrtat lous-In V, h, 6 V" h iI
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 Numberof 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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a--OWNER AUTHORIZATION-TO BE COMPLETED:WHEN
OWNERS AGENT OR CONTRAGTOR.APPLtES..FOR OUILDINJG PERMIT
ln�j.r Y .✓N ry E as Owner of the subject
property
hereby authorize _ �.�iqV'F C'
to act on ehalf, in all matters relative to work authorized by this building permit application.
• i
Signature of caner bate
6ek 17-6 as Owner/ uthor��
Age y declare that the statements and information on the foregoing application are true and accurate,to the best of my nowledge
antf belief.
Signed un a pains and penalties of perjury.
114--e
Print Name
�. 6 /,'/
Signature of er/Agent Date
^
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
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus b1dg&paved
#of Parking Spaces
(volume&Location)
A. Has a| Perm�/Vahance/Findi ever been issued for/on the s�o?
NO ��� DON7 KNOW 0 YES 0
IF YES, duteissue&
IF YES: Was the permit recorded a the Registry ofDeeds? '
NO �� D
�~� DON-r ^wvvv 0 YES
IF YES: enter Book Page! an d/or D onume nt#'
L__ |
'
��� VV v��
�
B. Does the site contain u brook, body or water orwetlands? NO v�� DON7KNO YES
IF YES, has permit been or need tu bm obtained from the Conservation Commission?
Needs tobmobtained v�� 0bta|ned x-� Date
^�� v~� ' .
C. Du 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 �~� kD� (17>1'
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading oUon.or filling)over 1 acre orinit part cia common plan
that will disturb over 1acre? YES � l NO y^A
�� "Li
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
`
fill
> City of Northampton
r
Building Department
212 Main Street
Room 100 u .
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMO!! E TWO rMOL ING
SECTION It-SITE,INFORMATION j t
Th n co e y offi
1.1 Property Address: ,
# u Unit -
SECTION 2—PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Zvi 1A /"O+� N1� �J �;rtG.�r� ✓£
Name(Print) Current Mailing Address: J�—7 9 T r,0
Telephone
Signature
2_Ai{horized Agent:
Name(Print) Current Mailing Address:
//3' z �� 7 T✓j
Sign Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building J r,-7 e O (a)Building Permit Fee
2. Electrical (b)�Estimated7otal Cost of
Constructionfrom 6
3. Plumbing N� Building'Permit Fee
4. Mechanical(HVAC) /
5.Fire Protection
6. Total=(1 +2+3+4+5) ,T70 D Check Number
This Section For'O:fficial Use Only
-Date -:
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2007-1205
APPLICANT/CONTACT PERSON DAVID CHICOINE
ADDRESS/PHONE 16 EDGE HILL PLACE AMHERST (413)246-7536
PROPERTY LOCATION 41 LINCOLN AVE
MAP 25C PARCEL 055 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
F e Paid
L43u9din2 Permit Filled out
ee Paid
Typeof Construction: Repair Porch
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 061582
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
NF 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 Commission
04 11 lo
Signatu e 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-2007-1205
GIS*#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
(o7661
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2007-1205
Project# JS-2007-001924
Est. Cost: $5700.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DAVID CHICOINE 061582
Lot Size(sq.ft.): 16509.24 Owner: MORGAN BARBARA&JANE AULISIO
Zoning: URB Applicant: DAVID CHICOINE
AT: 41 LINCOLN AVE
Applicant Address: Phone: Insurance:
16 EDGE HILL PLACE (413) 246-7536
AMHERSTMA01002 ISSUED ON.6/11/2007 0:00:00
TO PERFORM THE FOLLOWING WORK:Repair Porch
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 6/11/2007 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
41 LINCOLN AVE BP-2007-1205
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-055 CITY OF NORTHAMPTON
Lot: -001
Permit: BUk[M
Category_ BUILDING PERMIT
Pernut# BP-2007-1205
Project# JS-2007-001924
Est. Cost: $5700.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grog DAVID CHICOINE 061582
Lot Size(sg. ft.): 16509.24 Owner: MORGAN BARBARA &JANE AULISIO
7oninv URB Applicant: DAVID CHICOINE
A-T. 41 LINCOLN AVE
Auf;:ic:tnt Address: Phone: Insurance:
16 EDGE HILL PLACE (413) 246-7536
AMHERSTMA01002 ISSUED ON:6111120070:00:00
TO PERFORM THE FOLLOWING WORK.-Repair Porch
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 C Y OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGU LIONS. '`
Certificate of Occu anc Si nature:
FeeType: Date Paid: Amount: '
Building 6/11/2007 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo