25C-217 (2) �'Ct1AAlP�.
Grity of Xort4auipton
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5T1 -, DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northunpton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction supc� ,: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 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 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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1iF,YP,R"r?„EN"1' OP PUILDII�G INSPECTIONS
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` 2 nuI Street Munlclpal Budding
Northampton, —
Northampton, MRSS. 01060
NN'ORICEW S COMPENSATION INSURANCE AFFIDAVIT
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Permit i tumtx:r
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : JA \SO v �' S C)
License Number
Ad ress Expiration Date
Signature Telephone
'.°M,6P c.UFew n. `^WC. H vt iF '#
(9Ref�tered NomeImprbvemerit Contractor ;�,. Not Applicable ❑
pw
Company Name Registration Number
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 building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
1�. Borne e a n
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 lie/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 Nvill be required from time to time, during and upon
completion of the work fe-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 1,avvs 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 Zonni_ng� Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRII?TION OF.PROPOSED WORK(check'all apalicabl'e)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
/ Or Doors ❑
Accessory Bldg. ❑ DemolitionU m14tr New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Wo u1 Gti � * ��� /�4�+t+_ r �t�nv (�c�! 1� [Tr;.At/,1t
Alteration of existing bedroom Yes No Adding new bedroom Yes '` No
Attached Narrative❑ Renovating unfinished basement Yes '-'--No
Plans Attached Roll ❑ - Sheet❑
6a" If Newhouse;ard or."atliiifion'"to":existing=Fiousin complete-th0"161'lowin :
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 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 a =;OWNER',AUTHORIZATION -TO BE COMPLETED'WHEN
01WNEkS"AGENT"OR'CONTRACTOR APPLIES FOR BUILDING PERMIT
I, l�l,G6k Irre _, as Owner oft'ne subject property
hereby authorize k1 �son _ _ to ac; on
my behalf, in all matt rs 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.
Print Name
Signature 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 column 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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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:_
of Northampton S, t,
QI ding Department C. d
2 Main Street S
Room 100 * a er
N tha pton, MA 01060 aye s
,i ph X587- 240 Fax 413.587-1272 Plo it
r,NSPE
0*fher�Specffj�
APP Ln N TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This sectionfto be completed by office
1.1 Property Address: � �r„ _ =
3 (> 3 w A L!y tAT 5 l _ Map Lot Unit
N
01J tt AM PTO AJ Zone � 'v+ Ojuerlay�Distrlct
Elm St—District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
M IKE FoRar--S T 10 7
Name(Print) Current Mailing Address:
Telephone )
Signature 7 Kai 5
2.2 Authorized Agent: M A S S U 13 46
Name(Print) Current Mailing Address: —
Signature Telephone
SECTION,3 - ESTIMATED CONSTRUCTION_COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by perm(Lapplicant
1. 15� acv
Building (a) Building Permit Fee
----- ,
�I rival (b` stimated Total Cost of
Construction from 6
3. Plumbing i Building Permit Fee
4 Mechanical (HVAC) - ------ —
5. Fire Protection
6. Total = (l + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Onl
Building Permit Number: "/ ✓ Date Issued: —
Signature: ------------------ -
Building Commissioner/Inspector of Buildings Date
File#BP-2004-0141
APPLICANT/CONTACT PERSON JAY WATSON
ADDRESS/PHONE 24 SEVERANCE ST (413)625-9785
PROPERTY LOCATION 38 WALNUT ST
MAP 25C PARCEL 217 001 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: FRAME NEW C ILINGS PORCH REPAIR.REMOVE SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 079105
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 Commission
_�"-T o 3
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.
h �h; BP-2004-0141
GIS#: _ COMMONWEALTH OF MASSACHUSETTS
` CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category: BUILDING PERMIT
Permit# BP-2004-0141
Project# JS-2004-0217
Est.Cost: $15000.00
Fee:$75.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: JAY WATSON 079105
Lot Size(sa.ft.): 6272.64 Owner., FORREST MICHAEL&KATHERINE
Zoning:URC Applicant. JAY WATSON
AT. 38 WALNUT ST
Applicant Address: Phone: Insurance:
24 SEVERANCE ST (413) 625-9785
SHELBURNE FALLSMA01370 ISSUED ON:817103 0:00:00
TO PERFORM THE FOLLOWING WORK.-FRAME NEW CEILINGS, PORCH REPAIR, REMOVE
SHED
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 8/7/03 0:00:00 1585 $75.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo