25C-131 (7) ¢'SHAAfPl. '
of Narfhaniptan Z
� � �iilassac}ricsetts
DEPARTMENT OF BUILDD�G INSPECTIONS
INSPECTOR '212 Main Street * Municipal Building '
Northampton,MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as hds/her construction Super.,SupC:.,A so.r. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,a one'or tW6 -
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 fie 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 will call to schedule all required building inspections necessary for the building permit
issued-to me - -
Date-
Address of work
location
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R E (rif t of aIIiptoli
DEPARTMENT OP BUILDD\IG INSPPCTJONS -
212 Main Street ASunicipal Building
Northampton, Mass. 010G0
I
VVORIT-R'S CO'N'fPENSA770.N MSURA-NCE p,1'I'MAV1T
(li ccnsccJperml tt:cc)
%1.9 Lb a principal place of busioessfresidence at: ---
I
(su ticity/sZatclap)
do hereby certify, under tic-pains aad penalties of pcgury, :hat
{ ( ) I am an employer providing the follo%vin-'lxvorkcr's colnocns_non coverage for my
employccs «vorlang on this job:
(in_cu-r-:nc Comzsm (PaLic:Nv..m�-r) -- :pirvor. D21)
( ) I am a sole propr,ctor, general coDu-actor or homeowner (ci cie one) and have hired
the contractors lis below wbo have the following workers compen_t26on pckies:
i
('NaMC Oi C0�t7tctor) (Instranc Cotnpan)•lt GUCt- NUJMhC') nllc)
(Name of Connetor) (lnsirane;. C.omoanvi?oUc-V NLmiC2r) (-E%-D rrtion Date)
(Name of Conrlacto:) (Insurance Compan)-/PoUq- Name) (Exaimaoo Date)
l
(Name of Contractor) (insuraszc_ Cop
razy/Pobcy Nunaki) (Expiration D-- .
(.Mach —A4 Oc=j ca.ifnccczr_y to i'c"d-informamoa pcuinias to all ooc rcco s)
( ) I.am_a sole proprietor and have no one working for me_
(t)'l am.a home oNvner performing all the work myself.
NOTE_plea be tarot o.—.v) }c bac O.m,-.1 ubo auploy pcsom in c1�c• - csr�oo c rc,xa Boric cc.d—lL^;,of
not macs ibex _=is is wmeh the bom.—.,=r r=id=or ea the p-vu zppu�th,:.�-c ox C^.-..r_tly ctcd-ni to be
cavi-y`a tt the.-kcr z c==p - ca Act(GLI1 S2=I(5)).=pptinaon by a bomm=act fc-!ice«pc-ma r`7--id—tL-
I-S-1 ct asc or to e:Pioyx coder d,o W wlkd.Cooapomalioa AeC
1 uad--md tha a oopy or thi.ma=mma m.y be roc.ard.d to tha Dcp,nm yx of I.+d.cuiJ AcedtoD'off oe or 1—ror Ih+
I
oovuacc vcrirc3ioa and th_r L-iltac to caa=tovcn gc taadc socioa 23 A or MOL 153 na 1=-d to the iaxPO3-a6oa of c M;ZW pcn.+liio
masi::s or r=orup to S I Soo.00:.dlor 6=pr�orup to ooc yc=r tad c%i1 pm.tia in t5c form or.Stop Wort Ord-- sad a
5=orS100.00 a d_y LPIM:2 M-_
on J7 ------
- PcT$tt Nt1IDt)C7
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SECTION 8-CONSTRUCTION''SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
J. Zeaiser �� Not Applicable ❑
Company Name Registration Num er ----
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION`1NSURANCE.AFEIDAVIT{M:G
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 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 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 aadLocal Zoning aws d State o chusetts General Laws Annotated.
Homeowner Signature
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,i .
SECTION 5-DESCRIPTION OF PROPOSED WORK(check,all applicable)
New House ❑ Addition ❑- Replacement Windows Alteration(s) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [CD] Decks [[] Siding(01 Other[a
Brief Description of Proposed (
Work: A{,k1( U71 � k i C )- d- ba WL . S tuns
d'f
Alteration of existing bedroom Yes No Adding new bedroom Yes ~No .
Attached Narrative Renovating unfinished basement Yes
No
Plans Attached Roll -Sheet
6E1fMemft, ral i io #a exis ni i sln-(or,& a 1"M'e tam c
a. Use of build' :One Family Two Family_Jz--' Other
b. Number of rooms in ea mily unit: Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construc Dimensions
e. Number of stories?
f. Method of heating? 4 Fireplaces or Woodstoves 0^Number of each
g. Energy Conservation Compliance. Ma heck Energy Compliance form attached?
h. Type of construction W nQ ff- �'pi u47-o
I. Is construction within 100 ft.of wetlands? Yes No. Is constructio 'thin 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 6�
I. Septic Tank City Sewer Private well City water Supply
SECTION 7aOWNER AUTHORIZATION-TO BE COMPLETED WHEN
01NNERS AGENT OR CONTRACTOR-APPLIES'FOR JJU I"i ERMIT
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
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.
r
Print Name
Signature of 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
Frontage
Setbacks Front I
Side L:i R:` I L:' = R:I !
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved I c
parking)
f E
#of Parking Spaces —
Fill: r
volume,&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW er YES
IF YES, date issued: I
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
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
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,excayetion,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES ,. NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
J
l Build PP artment
� 212 Main istreet o
Room d0
1. AUG �onptA 01060
L-,---Ph-(4n-q_41_3-587-1240 413-587-1240 Flax 413-587-1272
DEPT 8 .
IS
APPLICATION TO CONSTRUCT,-AtTER',REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION.1,-SITE INFORMATION
This section to be completed baiffce
1.1 Property Address Y k� k
ry _ 3
{n'� //�� /�., verla�tstrict t
1if , V o lV OQl#.e
�FIm� Disfnct � � wCB.p�stnct�'
SECTION 2-PROPERTY OWNERSHIP./AUTHORIZED AGENT
2.1 Owner of Record: r-
C wolf I -ter PS )'� lq6t.1,ke S,- �r
Name Pri Curren Mailing Address:
Telephone
Signa-re
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 /f /�O F (a)Building Permit Fee
2. Electrical v (b)Estimated.Total Cost of
Construction from 6
3. Plumbing BLiildingcPernitFee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(I +2+3+4+5) Check Number
This Section For Official'Use-Only
Building Permit Number
Date
-Signature:
i
Building<Commissioner/Inspector of Buildings Date
File#BP-2006-0162
APPLICANT/CONTACT PERSON FORBES GWENDOLYN
ADDRESS/PHONE 113 MARKET ST#3 NORTHAMPTON (413)582-6196()
PROPERTY LOCATION 38 ELIZABETH ST
MAP 25C PARCEL 131 001 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 7;96 tnz:a
Typeof Construction: REMOVE&REPLACE KITCHEN&BATH WALLS&ADD CLOSET
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
INFgQ MATION 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 Commi ion
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.
38 ELIZABETH ST BP-2006-0162
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C- 131 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0162
Project# JS-2006-0249
Est.Cost: $1000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sc.ft.): 3397.68 Owner: FORBES GWENDOLYN
Zoning.URB Applicant. FORBES GWENDOLYN
AT. 38 ELIZABETH ST
Applicant Address: Phone: Insurance:
113 MARKET ST#3 (413) 582-6196 (�
NORTHAMPTONMA01060 ISSUED ON.8117105 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE & REPLACE KITCHEN & BATH WALLS &
ADD CLOSET
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 8/17/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
38 ELIZABETH ST BP-2006-0162
GIs #: COMMONWEALTH OF MASSACHUSETTS
Map Block: 25C- 131 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2006-0162
Project# IS-2006-0249
Est. Cost: $1000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 3397.68 Owner: FORGES GWENDOLYN
Zonim,::UPB Apnlicant: FORGES GWENDOLYN
_-----�----- AT: 38 ELIZABETH ST
Applicant Arldress: Phone: Insurance:
113 MARKET ST #3 (413) 582-6196 Q
NORTHAMPTON i ,A01060 ISSUED ON:8117105 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE & REPLACE KITCHEN & BATH WALLS &
ADD CLOSET
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:J✓�tt``� ,, D Rough: House# Foundation:
�yLL /� Driveway Final:
Final: , / , Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Roab;: Oil:
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 ~`°' i s�nature:
FeeType: Date Paid: Amount:
Building 8/17/05 O:OO:UO $50.00
212 Main Sheet,Phone(413)587-1240,Fax: (413)587-1272
Building Corrunissioner-Anthony Patillo
� P `