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` DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR 212 Main Street • Mmiicipad Building
+. y.
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMEZ 108.3.4 to
act as his/her construction sup L: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 tivo an::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 Dull Ing department forth-e"City oTNorthampton wants-any-personfs)-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 backfiII),
sonotube holes (before pour). a rough buildinE 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
-
is-sued-to me. .. _
Date-
Address of work
location
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Q DEPARTMENT OP DUILDr\G INSPECTION'S
212 Alain Street ' 'Municipal Building
I Norlhamplon, Macs. 01OGO
l w0RIC-LIZ'S COs!'II'ENSA-nGN L'iSU —A.NCE AI'I?II)�i.��77"
' pi�nsxl per;zy rice)
wiLh a principal place of business residence at: - —
i
(phone=')
I (sa t/dty/s=1:6p)
do hereby certify, under tic-pains and penalties of pcgury., ---hai
{ ( ) I am an employer providing the following 1«10rkc>✓5 COMOCASa:]O : covervgc for my
etnploycres woriong on this job:
(Ianir_nc Com=-z ) (Police:Number) (-,-pinion.DaL.)
( ) I am a sole proprietor, general coouacor or homeowner(cZ C:e one) and have hired
the contractors listed below cvbo have the foUo•vi.ne worker's comptp_,,adon policies:
i
(1,-;aDc of Co„-^Qor) (IILRr-dnt-- CornpaM-Pi oUCi D.ltc)
i
_ (Namc of Conraeior) (1nS-w--n= CompanyfPotie; `tlroccr) (E%-oiraiion Due)
(Name of Conrraao.) (Insuran= CompacyfpoUcy N mlu) (Expiry-don Date)
j
(Name of Connacior) gmsu== ComrzayfPolicy Numb-:r) (E%pir'6on D=).
(.M24h z21.'+s':;rxs!a3eC.st ncceza_-�•zo irlGt3d;iaforiL+�'oa pet..iaias to.11 coc-rvcz) .
I.am-a 5,G IC-proprietor and -bane no one wor'dng for me.
( ) I alit-a home owner performing all the work myself:
P is .,.3c bcmcawxn..tin 1 .vm to do t_a r, cs c c rgza cric as a d—U--Z of
NOTE: loge be cwZre �•.,•� �oy pc
one more tbee L=v_-%ru is which ttx bomoowoc raider oc ca the p ouin6 zppurtcm=tbeen r:ox to tic
eizploycs tzale the..-Oi—cc=p===IiOm Act(GU1 52-=1(.5)1 a.ppUcm.6oe by.bcmmava fc_!ice__or pe-mic=r C"d=,"LL,
Iega1 ct=, Of&=ee ptoyw under dto Wockr eL C.oepem.tioa Act
I yadcss�zd tts+t a ooyy of tbir citcmna may be f«-.vd.d w the Dcpn+imr�t oft-i•�^cl Acedcaz'office Of Iv+r+�far t6.
oovcz�c veilesioe�d lltat L-ilszc to swste'eovcrna^e tmdc soecion 23A of htQL 15-2 as lei to the hoc of ei=!c'!P—L'°
coesi agoC►fmc oftrP to S1S00.00-rwor imfsivo oCup to oa y-1 end a%j pco.hoo is t�fog of.Slap W°`� ''d a -
fzm Of S 1 00.00,day.Mast me
For:.�.�;=••••..'.�u,c onE-i—I
„"W G Permit 11tsrntKS
T./�ape Lot i
Signer of ic=�Ipctzniuc._ e
:
SECTION.8-CONSTRUCTION":SERVICES
8.1 Licensed Construction S ervisor:
c� Not Applicable ❑
Name of License Holder:- a,,
License Number �y
Address Expiration Date
Signatti re Telephone
1e"ink...QSrreare tra Not Applicable ❑
C a, ny Name Registratio""n-Number --
Address( Expiration Date
Telephone 6W 6 -20012
SECTION fO--WORKERS'COIrA PENSATIO[�iNSOEM,?, EAE�IET�Y jMGaE.c 152,�25C��y)
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...... ❑
9- 1 OW
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 1083_.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
SECTION 5--DESCRIPTION-,OF PROPOSEQW.ORK(check alhaaplicable)
New House ❑ Addition ❑;. Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Othe)o
Brief Description of Proposed / e
Work: -- -- �✓'e�(�C � CST UYt .S 7La-i
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sai l�tev�-�4�xs��,aiia ��. 1�t c�t�acis :rt stn
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? AJ b rt
d. Proposed Square footage of new construction. � .-f'/' . 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
SECTIO Za•-OWNER.xItJTItORIZATtON TOBECOM2CEFEQti1FF[ENt
OWNERS AGENT OF 'CONTt2ACTOR=API?UES FOR BCII INC PERMIT
I, as Owner of the subject
property
rhey home n y b*
ehalf in all matters relative to work authorized by this building permit application.31,
ature f Owner Date
7Ag t'4 c r. as Owner/Authorized
reby declare at 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.
Print N6rrn
Sign re of Own r/Agent 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 I '
Side L: R:' L:7 R:
r f
Rear
Building Height -— _--
Bldg.Square Footage %
Open Space Footage �^ % , !
(Lot area minus bldg&paved
r--
i 7 y
#of Parking Spaces
Fill: f
(volume I&Location)
A. Has a Spec'al Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT 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 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 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: ! j
E. Will the construction activity disturb(clearing,grading,exca on,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES , NO
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Nortl;lampton
Building Department
212 Main Street
Room 1,00
Northampton; MA 01060 r
phone 413-587-1240 Fax 413-587-1272 a
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENtOA*� O. IW0 ISF_A_ r TWO FAMILY DWELLING
SECTION T SITE INFORMATION "' ° 2105 /
x s., Tfiasect�ar> 15abe tefed byofce #
x
1.1 Property Address:
��� �:
,�+�iYY�� ,pY„r
SECTION 2-PROP.ERTYOWNERSHIPlAUTHORIZED.AGENT_
2.1 Owner of Record:
Name(Pint / Current Mailing Address:
Telephone 7
Cigna re rJ V I
2.2 Authorized Agent: _
Na (P nt) Current Mailing Address:
Si a Telephone
SECTION 3. -ESTIMATED-CONST,RUGTIUN.COSTS
Item - Estimated Cost(Dollars)to be - Official Use Only
completed by ermit applicant
1. Building 01) Z-, Bullding Petrhit Fee
2. Electrical (b).Estimated Total Cost of
Construction froth .6
3. Plumbing xBuildiog Permit.Fee,
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4-+5) J a -° 7D Gheck-Number
ThisSectioo=Foi Of ildid"Use OM
Date.:.,
Building�Permit:[Jumble- Issued:
Signature: '
i
Building Commissioner/Inspector of'Buildings- Date
File#BP-2006-0216
APPLICANT/CONTACT PERSON ANN E DOLLARD
ADDRESS/PHONE 142 RIVERSIDE DR FLORENCE (413)586-0742
PROPERTY LOCATION 59 NORTH ST
MAP 25C PARCEL 198 001 ZONE URC
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: REPLACE ORCH STAIRS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 087746
3 sets of Plans/Plot Plan
THE FPLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 Commission
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.
59 NORTH ST BP-2006-0216
GIS#: COMMONWEALTH OF MASSACHUSETTS
MU:Block: 25C- 198 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category Non structural interior renovations BUILDING PERMIT
Permit# BP-2006-0216
Project# JS-2006-0318
Est.Cost: $700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ANN E DOLLARD 087746
Lot Size(sa. ft.): 5967.72 Owner: d'ERRICO VAN GORDON LISA&
Zoning:URC Applicant: ANN E DOLLARD
AT. 59 NORTH ST
Applicant Address: Phone: Insurance:
142 RIVERSIDE DR (413) 586-0742
FLORENCEMA01062 ISSUED ON.813012005 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE PORCH STAIRS
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 8/30/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo