25C-122 (2) O �
�11AEE AC1t 1TE[tt8 n
DEPARTMENT OF BUILDIN G INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '
Northampton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as 1-:1s/her construction supra ,-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 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
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 n i i n . _ , L_.[1 J'_ -r_+1.., 4" 1,4:nn narmit
I will call to schedule all requli eu Uuiiuiiig iitSpCAAJUL1J icCcSSai y Lv. L11 vu=......b Y"-
issued to me.
Date
Address of work
location
� 4-�1tN-fpT
�0 C`c3
J Q f �1 a�aRrh null a'
c..o 0E PAR TMEI-IT OF BUILDf)\'G INSPPCT101.'S
212 Main Strcct Afunicipal Building, c
Northampton, Mass. 01060
41 l 'OIUCEIZ'S CO YMENSn nON LNSURA-NCE AI771Df{V1
{Ii�sxl pcTtn}titx)
\vIth a p ''pal place of businesslresiden at
(sn-�ticity/ fzip)
do hereby certify, under dic puns and penalties of pet'ury; that
( ) I am an employer providing the following wort cr s cotnoensct;on cove.-- nor Ind
i
ecuplovecs worLang on this job:
(iasus-an=Corr ) (folic;Nucabcr) (-_:-p,rUor, Dzj--)
O I am a sole proprietor, general contractor or homeowner (c cie o.r2el and lizve hirea
the coouactors listed below -who have the foDotviDg workers policies:
(i+IIID: Of Coninaar) (41R!ranc: COM03,l)'/t 06c N1UI h-_-) Datc)
i
(Mm c of CouczC100 (Insuraner Comoanyi?o6cy Nurcrr) (-EvD r (ion Date)
(Name of Connaelor) (Isutu-anez Compareyfpoucy Nambe.r) (Espu726oc Date)
(?�'zme c;Cvuu`dclar) (lnsZlfan Comry/Poliey Ntamly r) (Expiration Dasc)
(al Anh:.d ,;,cal ncccl ifncccii v to incud;iarorzn�Eoa pertaiaiag to�U ocsr-to:�)
{ I am a sole ro rietor and have no one w rh-in
P p o g for me.
( ) I am.a home owner perforning all the work myself.
NOTE:plcsc be awzm tfi.. -too cmplo),pczom to di maiz:ss= rrraa work oo.d%• U_Z of
got niece th n tt=o-t�ru is--bich the b=.c'_ rt raider«oa tLu avk a x7purtenn tbetn z c oa ocrs d=-cd m be
Cpl oyc-s unc c the..,�3 0=t ,�-- c.A� G L1 S 23a t 5
' ( ( ))r:-pptintioa by n homaoavc&:r a lice_a pcsmir tz=y cdcvoc cLc
jlc-¢I rtaasc of ea caployer under di WorFolr Compacsalioa Act-
I uodasuad dia:Dopy oC tai.m t c¢m t may bo f o r xnrdad to tbo D garimcoa oC Indusricl ncdd Off,00 o(!ru r�ooe for tlw
covcrxg `'a'zrc.a'cc and a--'L•iliac to soauc ho.crate Uadd=:1ioa 23A of h(oL 152 nn Icd to the iz poscioa of orimiWl pcaaLic
comtsiag of a fine orup to S1 500-00 and/«6=pri orup to woe year and Civil pcalp�a in be form ora Stop Work Ord,_-aad a
ft of S 100.00 a dxy
�J/J, For 6cq•rts`-��u.c oily
', 1.•fap°_— 1.01 n �•,
Signanuc of Lt tzzu cc e J
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable 0
Name of License Holder: 741A-I-) L� 61 Q�7 0 3
License Number
X17-
"
Addr xpiration Date
SighaUde Telephone
9. 2ea%stereil'Horrie=lm[iPouement ContracfoG KT Not Applicable .❑ _
Company Name Registration Number
j—/q'o7
Address 'Expiration Date
Telephone
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 buildinqR2nit.
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 Deauh)of Me:Massachusetts General Laws Annotated,vnn 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
s
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[O] Other[0]
Brief Description^�of PropKoseyl ) ; �
Work:
Alteration of existing bedroom Yes V No Adding new bedroom Yes No No
Attached Narrative Renovating unfinished basement Yes
Plans Attached Roll -Sheet
sa lTew'fiioase and oraditior> to.eicrstin' .tiousr� cam fielEe.tiefoll�ivirin
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'7a OWNER AUTHORIZATION-TO 13 E.COMPLETED-WHEN
OWNERS AGENT'OR CONTRACTORAO.PLIE'S FOR:BUILDlt G PERMIT
as Owner of the subject
property
hereby authorize A--L, tj
to act on my behalf, in all matters relative to work authorized by this building permit application.
ISignature of caner Date
I,
f" 1 z J6 v 1-J 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.
Signp.d under the pains, d penalties of perjury.
in
47'__
nature of Owner/Agen 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 bldg&paved
#of Parking Spaces
A. Has a Special Perm b/Vuriance/Find ing ever been issued for/on the site?
NO 0 DO07KNOW 0 YES 0
IF YES, data issued:
IF YES: Was the permit recorded at the Registry nf Deeds?
'
NO 0 DON7KNOW 0 YES
IF YES: enter Book ' Page!' and/or Document
'
B. Does the site contain a brook, body of water orwetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobe obtained ��\ Obtained �~� Date Issued:
^~� �~y ' . .
C. Do any signs exist onthe property? ��y? Y[3 ^_/ N� �~�
^
IF YES, describe size, type and location:
U. Are there any proposed changes toor additions uf signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E Will the construction activity disturb .grading,excavation,m filling)over 1 acre misdpart ofo common plan
thow0dismrbovar1oom? YEG ���& NO ���)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
,
E �
Degartmentuseuonty ,
--City of Northampton
C� (ding Department Gu ,Gtyt/QruewayPerrxut T
12 Main Street SewerlSpttcA+ra aatitjr `
Room 100 ` � .
W er vaita�tlittyatwr a
�5
APR 1 2006 Nampton, MA 01060x,
phone 418-587-1240 Fax 413-587-1272P ar�s ��
AF�P:LIGATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
S CTION 1 -:SITE INFORMATION
1 Provertv Address- a This sectwn to be completed by office
U If
^ � t"j t
_ V /���� Zone Overlay D�sfrict
Elm St:Dstc�ct..,;« :. CB District -
SECTION 2—PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
'?CFO 04
Name(Pri nt) Current Mailin Addre
4
Telephone
S nature
2.2 Authorized A ent:
ve, 6.4,,—) o
rint 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 0 [) (b)-Estimated-.-Total Cost of
Construction from 6
3. Plumbing obi d-v Building Permit Fee 50.00
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) a00 Check Number G S-U. CCU
This Section For Official Use Only
Building Permit Number. Date -"
Jssued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2006-1121
APPLICANT/CONTACT PERSON ALAN HOUGHTON
ADDRESS/PHONE 103 SOUTH ST NORTHAMPTON (413)210-0329 Q
P MON Z E aGE ST
mi ° u 122 0-0 `" URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
L,ffuilding Permit Filled out
wee Paid SU•cy It 2-13
Typeof Construction: Bath Kitchen Reno
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 ssion
Signature of Building fficial 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.
�tE ST BP-2006-1121
G1S#. COMMONWEALTH OF MASSACHUSETTS
IV
4 ,.w
CITY OF NORTHAMPTON
Lot: -00
Permit: Buildinq
Category: BUILDING PERMIT
Permit# BP-2006-1121
Project# JS-2006-1658
Est. Cost: $8200.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ALAN HOUGHTON
Lot Zoning: U ft.): 3615.48 Applicant:BIAPITA INC
ALAN HOUGHTON
AT. 218 BRIDGE ST �-
Applicant Address: Phone: Insurance:
103 SOUTH ST (413) 210-0329 ()
NORTHAMPTONMA01060 ISSUED ON:412012006 0:00:00
TO PERFORM THE FOLLOWING WORK.-Bath, Kitchen Reno
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 4/20/2006 0:00:00 $50.00282
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo