25C-160 (2) p4-StlAMP�O
�1g358[hli8[tt8
of Warthamptan
DEPARTMENT OF BUILDIJIG INSPECTIONS /
INSPECTOR '212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to
act as hds/her construction sups:v sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be,a one or two fame y
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 buil mg-depaitinent forthe-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 r',egulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfiIl),
sonotube holes (before pour). a rouEh 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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RJ E - �;+c7anc11 ntctf e'
I t
DE?ARTMEIrr OP BUILDr),�G INSPECTIOt.'s
212 Train Strcct Municipal Building
I Northampton, Mass. 01060
I
WORKER'S CONITENSAZZON MSURA-NCF All AV17-
i
-- —--MCI-Fly — ---
%VILi a principal place of businessfresidence al: - - --
��
(SII>wt/Ci tf/SZ3It1Zt p)
do hereby certify, under the.palns and penalties of penury, hzl
i
( ) I am an employer providing the followin-, Nvorkcr's comoe;nS_:io, coverage for Ind•
emplovccs worlong on this job:
- 0-1sur-n=Conn}) (Policy Nu-mbcr) -- (7:•pimaon DzL.)
i
( ) I am a sole proprctor, general contractor or homeow-Der (ci:c:e one) and have hired
the consactgrs listed below wbo have the following workers comoen-,P-don pokier:
i
(lL;am: Of Co"-^Cwr) (IRRi3nc: Coinpanl -/PObci l-,Iu1T1_G:) (Y`:wat on Datc)
I
I
(NzMc of Concaaor) (Ins-a=cc. C.omoaa}-1PoUm, `umc_r) (Emoirrion Datc)
-
(Name of C0a=clor
(Insu-anc: Compao}-/Po[ic�• N;un1z.r) (ExDirroen Datc)
(T'amc of Contractor) gmsurancz Compazygolicy Numbcr) (Exptrnon Daly).
' (atllGi.1_d:tst:oc31 s'.xd.irncc��_-v u a,cuc�in(o�x�ioa pev.inins to.17 eoc-�o:) _ _ - -
i {lam a sole pr-opraetor and have no one working for me.
( ) I am,a home owner performing all the work myself
NOTE:pl-,.be aorirc t+,,-w;-}n hemravaera wtw a 1oY p�,0=en So e• r e,00 a mr •oric as.d%%-Jl of
ont mote th:.e t'see t-Okl is ta'sch the bomoo+vc roido or oa tSe p-o ocS zppurtea✓1 lb.- z-c ax C-_,.rUy oc�d--Cd to be
eirployes und.r the..e S er a--''oa Act(GLI!52^1(5)) app[ic=6.o by a bommave fc a Lion.-or pc-min r=y e�-idco=the
lagr etz3ae of ea.sployx under do Workela Co¢pom,yion Act
r mad tha a--"of Chi-eat.em co m..y be for-.--id to tba pcpu.tmeat or Ine6+snJ A—a rd&OM-or Gs,+r+ooe for th.
c0%7 e-e reirjc=tioa amd that L-iitac to so=ot)cvcra tmdcr soRioa 25 A d MOL 151 ran trd to the iapositioa of eimiarl peaa.ltiee
--- of a fiat or up w S I-�OO.00 Kztdlor of up tv ooe yr_-and a�i1 p�.tio is be Corm o(.Stop Work Orde and.
rl=of S 100.00 a day cp, a ttx
Far dq.n�.�u,c onty
PCTIllit NumL--r
Lot I
Sizxlztuuc of Li tic: e -- !1
SECTION 8-CONSTRUCTION'SER1/ICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Re""isfereitort"reirr ereriEvacf6 -
Not Applicable ❑
Company Name Regis rati n um er ----"
;>G T,o X
Address f Expira ion D
L�li �i Telephone//3 --�91/ qf
SECTION 10-WORKERS'COMPENSATION:INSURANCE,AFFIDAVIT(M:GL.c.152,;§25CE&j)
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....... 9 • 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 and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
r
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check al applicable)
a.
New House Addition ❑; Replacement Windows Alterations) [J Roofing FF
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[o]
Brief Description of Proposed + I i
Work: IOUM- - 100� 01 Q--- QdreA,., vUA J c0dPkl 6e��Y4 l T
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
x.;
6a �i New io `se 'n a_=na to >CIS' i� i talstncr..cor sz>�ei t�i� ar[t� E g
"^^
of b;I:d'^^ n^�Fes., 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:BE.COMPLETED WH Nt
OWNERS AGENT OR CONTRACTORA�PLIES.FOR BUILMNG�PERMIT
as Owner of the subject
property
. � c
hereby authorize � m[!�� L t✓
to act7=y-bal;aV_in_all matt*relative t work authorized by this building permit application.
Signature of Owner Date
I, m L l) c e as Owner/Authorized
Agent hereby declare thaf 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.
--- -./ Lc_�
Print nKL;;L�_
Signature of Owner/Agent Date
Section 4. ZONING All Informatibn 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
j7
Frontage —
i
Setbacks Front i
Side L: R: ___ L:' R:'
Rear
Building Height F —.- —! r"" - —
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved i i
parking),
#of Parking Spaces r--
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
— -t
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW 0 YES 0
IF YES: enter Book Page and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued: E
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q r NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
-&'Nortf ampton trr s
V �n g Department �e
ain Street
om 100
N&A ptbn; AMA 01060
phone 413-5 7-1240 Fax 413-587-1272 to
QtherSseetfi!^ '
APPLtCA'TION Td-GANSTR(TCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1.-SITE INFORMATION
This sectrorr to be completed'by office
1.1 Prove rty Address:
,�NIa�-a dot � Una
' Zane O�erla�DtstrECt
ElrrrSt ��strrct CB Drstnct I
SECTION i2-PROPERTY`OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record::'
–~- Current Mailing Address: ' O,le)CY 6
Name Print , g
Telephone
Signature -� ? 7-
2.2 Authorized Agent:
Name P' Current Mailing Address:
Signature Telephone r
SECTION;3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building �9�� (a)Building Permit Fee
2. Electrical (.� (b)Estimated Totalr Cost of
Construction from 6
3. Plumbing Building Permit Fee.
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) d U Check Number
This Section For Official`Use Only
.Date
Building Permit Number. Issued:
Signature:
Building Commissioner/inspector of Buildings Date
' f
BP-2006-1163
GIS#: COMMONWEALTH OF MASSACHUSETTS
4�Rlogk-'25C- i60 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-1163
Project# JS-2006-1714
Est. Cost: $7000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TIMOTHY J LUCE 149288
Lot Size(sq. ft.): 14897.52 Owner: FISHER TIM
Zoning: URB Applicant: TIMOTHY J LUCE
AT. 4 ORCHARD ST
Applicant Address: Phone: Insurance:
P O BOX 14 (413) 387-9800
LEEDSMA01053 ISSUED ON.51112006 0:00:00
TO PERFORM THE FOLLOWING WORK.-NEW RUBBER ROOF OVER PORCH
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 5/1/2006 0:00:00 $25.004138
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo