25C-084 (5) GI-ity of Warthanyton L
�1834AC1j1t4[tf4
DEPARTMENT OF BUILDI7�,TG INSPECTIONS /
INSPECTOR '212 Main Street • Municip d 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 iris/her construction sup(..-„ 'ssor. T he state defines "Homeowner” as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fanu�--__ '
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 eegulations. 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
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
oy of ;
DEPARTMENT OP BUILDING INSPECTIONS
212 Alain Strcet IN-funicipal DwIding
Northampton, Mass. OIOGO
WO R1C4;R'S C O tYII'EN S A'n O N MS URA_N CE A F II)AATj-j'
(li ccnsxJprrm;t(cc)
-,14tli a principal place of businessfresidence at:
(phone--)
(sa�ticiry/stal.c�a p)
do hereby certify, under Cie.paint and penalties of pegury., :hat
( ) I am an employer providing the following L%vorkcr's colnocns_nao, covem�c for in),
emplovees worming on this job:
(Iasur_n=Conran y) (Polic.Nu-mbcr) -- (r':-pIrz or, Da .)
O I aj a sole rieto , general contractor or homeowner (ccie one) and have hired
the contrac�ors steel below vrho have the following workers compensation po�Icies:
(i+amc Of Cont^Cior) On_-urznct_ Compas'y Pobci
(Nzme of Coaczcior) Ons-wance Comoan`v,Potic; `urncrr) (i»iration Date)
(Name of Contractor) (Innuaric:.Compan}-frolic}- NamLu) (Expimdoa Datc)
I
(Name of Contractor) a=ranc-- Compaay/Pobcy Number) (Expirrtioc Date).
(an Ich_du":oczd rsca,if nccc .--to asciudr iarorm,:joa 9csSa-tnias to all coo;•-_co:�) .
I
1, I am'a sole proprietor and have no one wor4>3Bg for me.
j ( ) I am,a home owner performing all the work myself.
NOTE:pl=.=be acrsat t+„ L_:],hemrA.nvcra�to ecaplay pcsoaa to do W-oric oa.d..c1,-;of
aoe Mott th=Lbtutu in uixi6 the bomwo mw rcxide or oc the Q,=�appurtca-a tbcen t-r ox C=a.rcllp oerrd--cd to be
—Plor—1, e the--k=:cc:�c.Act(GUI 52.n 1(5)),=p9lin.6w try a bomnoava fcr a 6c=r-=a permit rr_•r c%id—M'e
icg c-tu of as c=ployx aadcr dso wcckr ec Coasgoasat-ioa Asx
I
I uodc,xxcd dad a oopy or thia mtcay==l y bo w tbo Dryortmcod or InduSricl Aced aXS'OCG—-fl—ror tbn
oovctasc vcir=ioa and thrl L•il=to sour kovcmr tnadx ioc iou 23A of MOL 152 esa lc d to the i=p a—of aimia p=-Ilt'°
oo�of a riot ortp to SI,Soo.00 uldror 6nPr6oac3c=oCu9 to ooe ycr and aril peaahua is be form of.Stop Wort order and
rsm of S1OO.QO s day LPjGst me
For dcq.r�u.c onf y
Le rcrm�t t`tttIDtkl LOt Sir,- - wrc of Li crrn ttcc
SECTION,8 CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date —
Signature Telephone
9`Rea ste�ec kforne t pea ine 6of t cto ,
Not Applicable ❑
Company Name Registration aum er- ---- --
Address Expiration Date
Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCE AFFIDAVIT'*_.G:L.c.1 2,§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...... ❑
ilk
At
�.
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 persons)
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
6
SECTION 5--DESCRIPTION OF PROPOSED WORK(check all applicable}
New House [] Addition ❑: Replacement Windows Alteration(s) ❑ Roofing
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[
Brief Description of Proposed ) \
Work: ty
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
saw.lNewrotse° o' - diia� cex �ic>bousle'IC : arpet :fh�far tur> cl:
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 Za-OWNER AUTHORIZATION TQ BE.COMPLETED WHEN,
OWNERS AGEN"T"OR l;ONTRAGTOR APPI l IS FOR'BUILbkGPERMIT-
as Owner of the subject
property --
hereby authorize Ca I aj/I'd-�.t &4,r"
to act on my behalf,i II matters relative to work authornz d by this building ermit a placation.
Si nature-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. '
Pn e
Signatu Owner/Agent Date
Section 4. ZONING All Informatioh 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 E
Frontage
Setbacks Front
i
Side L: R L.! R:'
Rear
Building Height — -
i
Bldg.Square Footage ; %
I--mss
Open Space Footage %
(Lot area minus bldg&paved
parking)
r—°
#of Parking Spaces j
Fill:
(volume-&Location)
A. Has a Sp cial Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book 1 Page' r and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO (7r 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 0 Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location: 3
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO l
3
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,exca tion,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 - NO
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r
City of Northampton
wilding Department
j 212 Main Street S'
' Room 100 '
0 .Kok ampton; MA 01060
phone-.413-51 7-1240 Fax 413-587-1272 PtotSltfan �
is 0te�peetfy � � ��
APPLICATION TO CONZTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATIO
This sect rr to be?catnfetecf E� ace
1.1 Pro ert�Address: Q�
Y U
�i'� LOt a� Untt
a ono OverfayDfsct
EfmSt DIStrIG� w_ CB D�stnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED.AGENT
2.1 Owner of Record:
on
Name Print) Current Mailing ACdress;��
Telephone
Signature
2.2 Authorized Agent:
a Current Mailing Address:
``1 l C -7� &`1'�
Signa ure Telephone
SECTION 3-ESTIMATEDCONSTRUCTION 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) T Check Number
This Section For Official Use Onl
,Date
Building Permit Number. Issued':
Signature: r
Building Commissioner/inspector of Buildings Date
File#BP-2005-1272 r 2
APPLICANT/CONTACT PERSON CDT CONSTRUCTION
ADDRESS/PHONE 158 NORTH MAPLE ST FLORENCE (413)585-8677
PROPERTY LOCATION BRIDGE ST-SHELDON FIELD
MAP 25C PARCEL 084 001 ZONE URA
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: INSTALL COVERED DUGOUTS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 003666
3 sets of Plans/Plot Plan
THE FqLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION 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 Commiss'
Signature of Bui ing 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.
BRIDGE ST-SHELDON FIELD BP-2005-1272
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-084 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildlnq
Category: BUILDING PERMIT
Permit# BP-2005-1272
Project# JS-2005-1700
Est.Cost: $1000.00
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CDT CONSTRUCTION 003666
Lot Size(sg. £t.): 442569.60 Owner: CITY OF NORTHAMPTON
Zoning:URA Applicant: CDT CONSTRUCTION
AT. BRIDGE ST- SHELDON FIELD
Applicant Address: Phone: Insurance:
158 NORTH MAPLE ST (413) 585-8677 Workers
Compensation
FLORENCEMA01062 ISSUED ON.6122105 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL COVERED DUGOUTS
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 6/22/05 0:00:00 $0.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo