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is. DEPARTMENT OF BUILDING 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 his/her construction supe .,;sor. 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 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.
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
requiye4 can DELAY the project until such time as the proper permits and inspections are
mad
46k"n kq�&� understand the above.
( e o` ner/ si ent'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 n �
location � A 4,
Cll,zfy> z�f 'arfljallt}lfLill `
6 rtlK�5ACilnsctla ' L
DEPARTMENT Of' £UILDPJ G INSPECTIONS
212 Alain Street , Municipal Building
Northampton, Mass. 01060
WORICER'S COMPENSATION INSURANCE ATFUMVI-T
I,
;:"ith a principal place of business/res denec I:
do hefeoy ccr-ul},, l::]:' I' die iii:iilS 111ii7 pC it l 105 oI pi-rJur-r, ilia!
am an crnployei- providing, the io110'.'.'ii]S_ '.'1,01 t_Cr"S GOII]pCnsaUo1] COVCra' C 'Or Iny
eillplovices Working un t?liS job:
(InslranG Comp m•) ci:c,Number) ---- (r�.�ar.:ticn Date)
I a�i a sole proprietor, -,en.-FL cons�c cr <z�s,omco.�ne: cle Oct) and gave hires
the contractors fisted bel ; r
o I�.e s c:ompen�: on T1 is es:
c of CO ILMCtor) Lrs -ncc cr.,n.:.:If:Pc!ic; Zlusntcr) ;� . .,icr Datc)
(Name of Contractor) -- (1-asur_nce Come .`(Pe!ier Ntrl rr; (Ex .aiin, Date)
— -- — --------—
(Namc of Contract
or) (Inslr�]ce t_o;;];•tIfol.c, Nusi]tx _-.z-1. , Late)
- (Name of Contrlctcr) —- (Ins1 rand Cotnr };IPoli y Numb,--r) - (F;xr;i-aie.-Date)
(^.[IZGl ad�i;imal zi>st is s:orcv-:•o:-c1'.�.�:-.:-Y , , _ _ � -< _ 1 .
O I lull a sole v c Brie ,; c
lOr
am <a l:011]e
NOTE:plcysc In awa:c tha:•.vl Ic ta;co•^Zra u; r.�! P'= '•: ._ m rt:cpair:
not UKcc thn throe uui[lj i,ut dt he f .. ,ur.=7 :�J V IXi '_:�.: 1 ^11 t Ct D C A 4 LGYSIII'i oar.•';.`` i�
cII*.ployc3 u.•k�cs 4x_wcc�,ri a c :�: :aim ,.ira•ic:: y a hncnro«�cr for a
Icga1 na ,'
tua of an aMplo)w uocr t11n Woritc'.
I uadcz:xnd d1i a copy of trig ctatc:-s_•say bo fo,wvcto-:f to[r;a[Ytiartarszt of Ir.�utri:.l AcviL�tf Cllioo of i:::+ir�:a foi t!x
cov—&c va-ifictioc and that f_ilure to:n-r co ur e"iM 2SA of MCI.152 can le_ci to the irnpoSitim of r- -1 paaL•_cs
c'omutmg aft,fur_of up to S i,SO .O-o an&,c c i^:;r: ti;. o f up to rr,:} r.-.1 civil periltia in d c f,-nn c.f.,S:r,
Lr--oCS10000 a dsy artina m..
For 1116`1y
crinit NIInllX;r
:IT)"
lSJJ ---- .,). - --
fur
'ON* -`:CONSTRUC,TION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Re"�s�ere =m rover• + , _ �.=. Not Applicable
❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTIONIO VIIORKERS'eCOMPENSATION INSURANCE,AFFIDAVIT(M:G:L. a 152, § 250(6))
F._
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...... ❑
• cull':-.
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 them
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"homeo-wner"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 fe-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"certi nd assumes responsibility f r compliance with the State Building Code,-City-of-
Northampton Ordinance , State Loc I Zoning Laws and State o ass chusetts General Laws Annotated.
g
Homeowner Si nature
V
SECTfON v:DESCR�KaiI4VN10Fl.PRDP0SED WORK check all a licab1e
+fi .wnk '80
'. i TM3 rY?',e"°` "
a
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ) Other rr�'
rief Description of Proposed Work: la�oge Gmx)a O\k),_\ (k�� }� '�( �`� V4 �-
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes No ��
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
6a'�Lfi N ew ho'"u e a d.or .dd"ition.to eXisting housi"n'g cotnple e, fft.'
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. Mascheck 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
SECTlQN7aUINNER AUTHORIZATION TO"BE'COMPLETED WHEN
:OWNERSAOENTO �CONTRACTOR APPLhES:FOR BUILDING,P�ERI�IIT-' i
�CN- -Nrn%'� A �� t as Owner of the subject property
hereb authorize �O �_ to act. on
My h If, in all matters r ativ to work authorized by this building perm 1t application.
JA
i o Owner Date `
I' as Owner/.Authorized Agent
hereby de lare 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 arLd penalties of perjury.
-�\Yl
Pr nt me VV
Si f n r/ gent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
ry Building Department
Lot Size
Frontage
Setbacks Front 9%1 (o
Side L:=5 R: L: 3 b R: 3 O r
0 ON
Rear �. �(' 6 I a 2
Is
Building Height l' f" 1
`� he tgM-
Bldg. Square Footage % 1,5 t X i
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume'&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued:
C. Do any signs exist on the property? YES NO X
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:
of Northampton
On
�ON
n artment
. ! a rhi Street
100
JUN
r 6 ! a MA 01060
( hone 413-587- 240 Fax 413-587-1272 ' #
P((i! �.�
D � INS ONS
----------- G
Mw,_ T
APPLICATION TO D , Fp R, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
u This section to be completed by affrce
ropertx Address:
1.1 P W R
6 H (;r A N-T >A V
�a
'�,�� +gym�� ➢. t `� z ' 4K, k 7 � at„8 ,-k`` a
1�1 car-�1nA�cY1(�—oN
Zone OvedaD�stnct
�
SECTION 2.-'PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
'- n K e [D!—Gr)ryt Avg N *+6kJ O td(cO
Name P'nt) Current Mailin d919 y-�
2
1 r Vk Telephone
Si atu e q19UN
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 Pa 3 (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 This Section For'Officiat Use-Onl
Building Permit Number: — 0 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-1290
APPLICANT/CONTACT PERSON SCHMITTLEIN LYNN M&MARK F
ADDRESS/PHONE 64 GRANT AVE NORTHAMPTON 584-1937
PROPERTY LOCATION 64 GRANT AVE
MAP 25C PARCEL 115 001 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: INS*L 24'ABOVE GROUND POOL
New Construction
Non Structural interior renovations
Addition to Existing -
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THFpproved OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFTION PRESENTED:
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 sion
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.
64 GRANT AVE BP-2004-1290
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C- 115 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category. BUILDING PERMIT
Permit# BP-2004-1290
Project# IS-2004-1942
Est.Cost: $5193.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa.ft.): 9321.84 Owner: SCHMITTLEIN LYNN M&MARK F
Zoning.URB Applicant: SCHMITTLEIN LYNN M & MARK F
AT: 64 GRANT AVE
Applicant Address: Phone: Insurance:
64 GRANT AVE 0 584-1937 O
NORTHAMPTON MAO 1060 ISSUED ON:6122104 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 24' ABOVE GROUND POOL
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• Receipt No: Date Paid: Check No: Amount:
Building 6/22/04 0:00:00 2345 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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64 GRANT AVE BP-2004-1290
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C- 115 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category BUILDING PERMIT
Permit# BP-2004-1290
Project# JS-2004-1942
Est.Cost: $5193.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 9321.84 Owner: SCHMITTLEIN LYNN M&MARK F
zoning uRB Applicant: SCHMITTLEIN LYNN M & MARK F
A T. 64- "3P.ANI-4' F
Applicant Address: Phone: Insurance:
64 GRANT AVE 0 584-1937 (�
NORTHAMPTON MAO 1060 ISSUED ON.6122104 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 24' ABOVE GROUND POOL
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 Deuartment Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:oh- C7—1,-3,0 �
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATIO F
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 6/22/04 0:00:00 2345 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo