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�-, 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 iris/her construction sups, ,i-or. 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
1, 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
11-T17 >1� �:\LT1IlJ�1711�Jf[111 .
E �S�a55 AC}1115CIIe
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DEPART MENr Of I3UILDI?�G INSPECTIONS
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212 Main Street ' Municipal" .o
Northampton, Mass. 01060
WORICER'S COMI TENSATTON INSURANCE AI+ITT)ANIT
,, itffi a principal place of bush ess/rc: dcnce
(strc:t_icitri;�?.u:�,--'P) C11C7(:1
do hcrcby ccr'ufI unfit-1- die, �!)<:!i1S anj pcn-2itics 01 pe.r3U1�', iSla:;
am an empiayer prOV]C}ing t}le i0llo�'Jlt? :Or'rC1`5 C0117i)Cf1S?LlOi� GOVCS2JC i0' iI7}'
employees W06 ing on this job:
AA
- (InrlranG: C�oc�^�•�m') i e�cr?.u:rttx:) (`- .�.ir;non Date)
! ) 1 am a sole proun'tior, general c-Dnt= or ,_,f homeo"-I�Del. Icl Cle Oct) ?lid h2ve hued
t.l;e contactors listed beiov, ;`:o oll ;porkers cOr pens son ! —s:
(Na-me of Contmctor) (IR:Lr';1 C:, Cvm--,.'i i:ri Gllt={ Nu-mb--T) iT,.'..? ..:,1C' Date)
(Name of CaZtr:ctor) -- (111sIr._nce Co y_ �'�Pelic'Ntnkrr) (1 r,:tin Date)
(Name of Contractor) (Insl-dlcz Co E;�n.;l?olic: Ntunr��r) -z;.:r.:doa Datc)
- (Name of Contrlctor) — - (II7S�P�I1C Comr Yly,Policy Number) (H xr_i-aior Date)-
( 1 am is sOlc 1)1 Upr]CL`Ji ii?!'1 I7SV il0 for al •.
I (am a home 'all t! . i:i'rSClt.
NOTE.:plcasc be nn-n:c tl:sc'.Eilc lx<rca r .o r.n !may to :-;?au
not ukxc th_n tluoo units in tvL!dt C'a; _:._s xa-•r crsrl lhcr c e c r'��c xra11Y c: .::):,r::c:o h
ets�ploye�u.��s t}r tvc:i;:r's cc�.-�:a!icn
Ac-(GL!52,::c!( )!,a,:;._e.:ic::I a h,:nrott-ter:`cr r cc
uric
les-I ctatuc of an wMplo)w unu' tin Wcukclz Co.m--w _.lion!.cL
I undc^zt. d the a copy of this c:.y F.,o f,s--cic•1 to tlrs[Ytiortzrn:of Iz.diutri+l Mir r:�r�If of't:::,_�r.rr:A for tfx
coves-q�c vaific-_tioa and that failure to :c,:,,ioa 25A of M01.152 can lc:c,4 to tI)e impo>itioa c ir-1 pe -likes
cvmi-tting of a fur_of up to 14S-0.0 n: 'n c:fir:.,YZti:1 oft;p to nr._}- ..-.i civil p=utticz in yc frrrn c.f.,Str, );'ni ==A
Lrv•of SI00.00 a diy a;�-in:t m:. -
_ For dci%ssut "j u,c utly
;t1ap.I
J:fin. urct�fl.ic�tcJI'ernr.ttc.
S�CT�ONR CONSTRUCTION SERVICES
8 1 Licensed Construction Superviso/r;_(, Not Applicable ❑
Name of License Holder : l(JC Vd 7
License Number
Addre s ' Expiration Date
73
Sig ture Telephone
Rees erg :o 1�6fim6htWv Wraciv� `` Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 30 WORKERS' COMPENSATION INSURANCE (6))
..AFFIDAVIT(M:GL. c. 152, § 25C
ri ,.
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....... le No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied DWellinLs 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"homeo-wrier"shall submit to the Building Official, on a form acecptable 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 15') (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 and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
FTIOTJ OF PROPOSEWWORK hec I a I�calile
i
New House ❑ Addition ❑ Replacement Windows Alteration(s))( Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolitiow New Signs [ ] Decks
[ ) Siding[ Other ]
Brief Description of Proposed Work: t o" S 0
cx ca
1.0 eA-t*-K
Alteration of existing bedroom Yes X No Adding n bedroom Yes No
Attached Narrative 0 Renovating unfinished basement No X No
Plans Attached Roll 0• Sheet 0
6a a _ u a atldition "to existing hoes"ing co��°he �llowin
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 Nc
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
SEClt3t�C�° VKR�I�TlORIZATION' TO BE COMPLETED WHEN
OWIfSAN�OECONTRACTQR APPt_IES, F0R BU,i't DINGPERMiT
�— as Owner of the subject property
hereby authorize Ce i,--J �� to ac;. or
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
L 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 p ins and penalties of perjury.
Print N e
1412"�—
Si at a of Owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This colurrm to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
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
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:
+;. City of Northampton
r 4 .
�, �U ► -,- __ !wilding Department
212 Main Street
Room 100
r r' North mpton, MA 01060
__phone 413-58 -1240 Fax 413-587-1272 u`
-APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION-
d ;
Thrs sectron y oWbice
1.1 Property Address:
���
1 (�rCr� Mai k unat
Zoue byetlait Dlstnct
�Inv .rJ5ti7Ct a CB �e7Ct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT';
2.1 Owner of Record:
Nam (print Current Mailing Address:
/ a s 21�j — .4 v s�
i Telephone
Sig ature
2.22 Authorized Agent: ,p
12 r ,� r�a Imo► �c�i✓� �1' Y o 1 V lcu e�
Nam Print) Current Mailing Address: 01070
--v4v, '_ )
- �3y--573
Sign re Telephone
SECTION 3-ESIIMATfD CONSTRUCTION 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 fi
3. Plumbing building Permit Fees
4. Mechanical(HVAC)
5. Fire Protection
6. Total = (l + 2+ 3 +4+ 5) i"Che:ck NumberC?
This Section For Official-UseOnl
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-0809
APPLICANT/CONTACT PERSON GERALD ARCHAMBAULT
ADDRESS/PHONE 263 PROSPECT ST PLAINFIELD (413) 634-5739 Q
PROPERTY LOCATION 13-15 ORCHARD ST
MAP 25C PARCEL 152 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ZONING FORM FILLED OUT ENCLOSED REQUIRED DATE
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 3RD FLR STAIRS TO EXTEND 2ND FLR APARTMENT GUT 3RD FLR
&REPAIR SIDE PORCHES
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License 010788
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Co ssion
y' Loo
Signature of Building Official Dat
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.
13-15 ORCHARD ST BP-2004-0809
GIs#: COMMONWEALTH OF MASSACHUSETTS
Ma :Block:25C- 152 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2004-0809
Project# JS-2004-0992
Est. Cost: $8000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GERALD ARCHAMBAULT 010788
Lot Size(sq. ft.): 6011.28 Owner: HOMSTEAD BRUCE R&LAURAL A
zoning URB Applicant: GERALD ARCHAMBAULT
AT: 13-15 ORCHARD ST
Applicant Address: Phone: Insurance:
263 PROSPECT ST (413)634-5739 () Workers
Compensation
PLAIN FIELDMA01070 ISSUED ON.2120104 0:00.00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 3RD FLR STAIRS TO EXTEND 2ND
FLR APARTMENT, GUT 3RD FLR & REPAIR SIDE PORCHES
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 2/20/04 0:00:00 456 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
+
+ +
Loi.GA NOT11%olt
v Date �2 ` 11-d y
Article , Section of the Zoning Ordinance
WHEREAS, violations of Article / IS-% I , Section 766 CM of the Building Code have been found on
Article 1 Lq, I , Section of the Code
these premises, IT IS HEREBY ORDERED in accordance with the above Code that all persons cease, desist
from, and
S-' To WORK
at once pertaining to construction, alterations or repairs on these premises
known as 17— t t` ORCHARD _G7_
All persons acting contrary to this order or removing or mutilating this notice are liable to arrest
unless such action is authorized by the Depar tnent.
u LDING 04161AL