25C-249 (2) ��
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..Cz#1y of Nort4amptan ti
Z
$ 8 jlTriassac3tusetts -
DEPARTMENT OF BUILDIJ,,TG INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building '''�44
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction sup<:: .e 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 fami[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 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 eegulations. 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
ayY1l�SL, 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 �S l (o- c)1
Address of work
location �_ -'
L
i
o4tttn}r ATO r..
of ParfIlzaI11pfml -
i
��aosarllnsrlla• _
d DEPARTMENT OF BUILDING INSPECTI() -
j 212 Main Strect Municipal Building
Northampton, Mass. 01060
WORICER•S COMTENSATION MSURA.NCE AFFM,,,vii"
i
I (I1 COL1S�'JpC TrI1i f 1C�)
vVith a prMi cipal place of businessfresidence at: —
(ph one:=)
i
(s>? tici ty/stain ri p)
do hereby certify, under the.pains and penalties of pc hac
( ) I am an employer providing tSie followmc Nvorkcr's comocnsado, covemSc for in)
elnpiovecs WorUng on thus job:
I
(Lnsur-am Conr ) (Polic:Number) (T:piruoa D2-) "
i
I am a sole propnetor, general coon-actor homeowner ( Cie one) and Lave hired
the conTaCprs listed below who have the follow' mg worke s GOmJen_taaon Pak*es:
(l amc Oi Co.`,'TncioF) (Insurancc Coinoan)Y�GUC� NUII1-Cr) ?:JIiJ;:^i?1�:11C)
i
(Name of Contrmor) (Iilstianec C.omoa -vi'Poscv `wocrt) (! a�Lm6on Date)
i
i
(Name of Couzaaor) (Instuanc:Compan)•/PoUcy Nambj) (Expimrios Datc)
I
i
(Name of Coutractar) (Insurance Company/Policy Ntimb`r) (Expimdoa Datc).
(aIIar'j.�l�:i oC31 tf acoQa_^v to iafora-=i—pcna; to.11
O I am a sole proprietor and have no one work-ing for me.
i
I am.a home owner performing all the work rnysdf.
NOTE:pl=se lx ewlre th,k e banco,vcrs to cl=PIoY PCS.C>u t0 d:) - =s=00 r rtaaa we w a d.•ctL^�of
not mat tb a tbso imita is«��tix bomoownc rvid�or oa clu vein+,z9�tbee_ c,we c=r_1}y W=.daoi Lo L+
etxPloycs twc a the--k---u:o=mp---*'oa Act(GLI5Zn 1(5)).=WLin 000 try a hoa=mma ref a Gem_or pamn 2y e i&m the
Ic¢I ctanic of at e=Ployar under tho Workcli Compomalio¢Act
I
- 1 uadc-rzaad thin a Dopy of thin etalemesa nlay ba fo-I—tnd b LEo oepartmcod of lodurrial A.&.1'offioo of L_--ooa for
covesxSc nzirenioo e.nd Chet L-iltzc a sonuc tovctb se uod�r stloa 23 A of 1.(C)L 1 S1 cs amd to the i=posidou of criminsl Pcaaltic
ooaw.mg of a ride oruP to S1,�00.00 andla 6MP6y�amc=oruP to Doc ycr etd a.il peoaP.ia in 6c form era Stop Work Ordc and a
rim of S 100.00 a dq apIc:a me
For dry=rta+-�,t u.c only
Permit)Number —
M1p:—_ L,ot �.
Siinatur -oru=--j Crmitics _ -1
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor; Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
. � r Not Applicable ❑
9`Re6 stei�cTHon'ie-Tff6W, e'rrtent ontraic di~
XCLV,'►U 1�3d��c SS
Company Name Registration um er —"--"- --
Addre/ss�+ _ / lee(l� Expiration Date
Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCE AFFIDAYI7T`(M.0 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...... ❑
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 rime,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, ..,, ,
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [] Addition ❑. Replacement Windows Alteration(s) Roofing ❑
Or Doors ED
Accessory Bldg. ❑ Demolition' ❑ New Signs [0] Decks [p Siding[ft Other[E j
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a INIeW housean aadditt to existnciorislna:.corlpei€ .fG� f�fQUl�t :
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. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodpfain 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 Ta-OWNER AUTHORIZATION=TOBE COMPLETED'WHEN
OWNERS-AGENT.ORC.ONTRA'GTOR APPLIES FORBUIL6114PERMIT-
I as Owner of the subject
property
hereby authorize v
to act on my behalf,in all Ttte relative to wor thor d by this building permit application.
Signature of Owner Date
I //Yrt v .J au lcc 5 S 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.
/// L •/ r s1/ /oS U�(''C 5 S
Print Name
Si ature of Own gent Date
' .
`
Section 4. ZONING All Informati6h 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
Setbacks Front
Rear
Building Height
Bldg. Square Footage -1 %
Open Space Footage %
(Lot area minus bldg&paved
of Parking Spaces
(volume&Location)
�
A. Has Special Perm it/Varia nce/Fi ndi � everbeen issued for/on the site?
NQ 0 DON7KNOW 0 YES 0
�
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO K J DO07 KNOW 0 'ES
IF YES: enter Book Page and/or Dooument#
�� ��
B. Does the site contain a brook, body uf water orwetlands? NO �~��� DON7KNOVV �~� YES �_/
IF YES, has permit been or need tobe obtained from the Conservation Commission?
'
Needs tobaobtained x~~\ Qbtained �~� Date Issued:
�_� v_� ' '
��
C. Do any signs exist un the propar�? YES �~� NO
IF YES, describe size, type and location:
D. A-ra�there any proposed changes to or additions of signs intended for the property? YES 0 NO
'—
'
IF YES. describe size, type and |ucutun:
E Will the construction activity disturb or filling)over 1acre or is it part ofncommon plan
that will disturb over 1ome? YES NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Nortf ampton Sta
Building Department
212 Main Street
Room 100 W5,
� � Northampton; MA 01060 � X� �kx, {phone 413-5$7-1240 Fax 413-587-1272 tc — SIZ
i
APPLICA11QN TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1.-SITE.'INFORMATION
1.1 Property Address:
Th�s'.sectron to be compI tedBbKofftce
UrEfi
O I r� Map Lot
���� �� M/J i� '`J Zane x 0uerlay Dtsfnct
g aS
1 Etta S Distr►ct C&D4stricf
SECTION,2-PROPERTYOWNERSHIP/AUTHORIZED AGENT
`
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Is
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
1
Signa re Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building / D (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction.from 6
3. Plumbing Building,Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Gheck Number
This'Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings- Date
r
r
File#BP-2005-1140
APPLICANT/CONTACT PERSON BELMORE STEVEN D&DELORES M
ADDRESS/PHONE 41 OLD FERRY RD NORTHAMPTON ()587-0288 Q
PROPERTY LOCATION 41 OLD FERRY RD
MAP 25C PARCEL 249 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out IJ
Fee Paid
T}peof Construction: ENCLOSE NONT PORCH&INSTALL SIDING
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
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
s' 2 OC
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.
e
41 OLD FERRY RD BP-2005-1140
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-249 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1140
Project# JS-2005-1542
Est. Cost: $142060.00
Fee:$70.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: Homeowner as Contractor
Lot Size(sa. ft.): 8581.32 Owner: BELMORE STEVEN D&DELORES M
Zonin :URA Applicant• BELMORE STEVEN D & DELORES M
AT. 41 OLD FERRY RD
Applicant Address: Phone: Insurance:
41 OLD FERRY RD O 587-0288 0
NORTHAMPTON MAO 1060 ISSUED ON.5119105 0:00:00
TO PERFORM THE FOLLOWING WORK.-ENCLOSE FRONT PORCH & INSTALL SIDING
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 5/19/05 0:00:00 $70.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
MORTGAGE LOAN INSPECTION
THIS PLAT IS FOR IDENTIFICATION PURPOSES ONLY AND DOES NOT CONSTITUTE A PROPERTY SURVEY
j 75'f
NOTE: PROPERTY LINES AS TAKEN FROM
CITY OF NORTHAMPTON ASSESSCRS MAPS
AND ARE APPROXIMATE ONLY
�t3`
DECK
2 STORY if C
I HOUSE 6ea0e(
1
.av ,
I < I -
v I PORCH
L I 7b'± I
OLD FERRY ROAD
THE PREMISES SHOWN ARE SUE ECT TO AND/OR TOGETHER WITH THE
SENEPTS OF ANY AND ALL EASEMENTS, RIGHTS, CONDITIONS, COVENANTS,
AGREEMENTS, RESERVATIONS AND RESTRICTIONS OF RECORD.
5G THE CHARTER ONE BANK, FSB AND TkIE
FIRST AMERICAN TITLE INSURANCE COMPANY - ONLY
.__.
?o mr knawiedge, mformal'rn and belief, iron information supplied to me, I hereby report that the premises hove been examined and that
inspection p,at shows the i.,orovement or ;mpr snorts as located nn the premises described, !hut the improvement or;mpro•rsmens
ere entirely *;thin lot Gnea that there ore r,o ancroach.mants upon the prenises cesarbed by the improvement or improvements
'cli6nmg premises. and that there ore no easemeats of record oftectlny the Tract shown hereon, except as shown.
1 IuAter report that ALL-)E the premises ehawn on this plan ARE located within c n000 Hozcro Area (Zons A13) OF
and R appears that tttr improvemenb erown tttt located within that Flood Hazard Area as shown on the PAUL
Department of H.J.G. Federoi insuran;e Administration MODS,
2sots� 0002 a f` ee
Community Number
ld—w.canon Data
HUNTLEY
OWNER KURT A.
& CAROL A.. BLA BLAHA
ALMER HUNTLEY, JR. & ASSOCIATES, INC. LOCATION 41 OLD FERRY ROAD
Surveyors a Engineers - Landscape Architects NORTHAMPTON, MASSACHUSETTS
30 industrial Dave East
Northampton, MA 01060 Joe NO- JDATE SCALE
voiCe(413)584-74.44 faz(413)586-9159 00-719 10/31/2000 1"= 20'
t
10. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
Are there any proposed changes to or additions of signs intended for the property? YES_NO_ZZ--'
IF YES, describe size, type and location:
11. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 cre or is it part of a common
plan of development that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION
This column reserved
for use by the Building
Department
EXISTING PROPOSED IDyBY
Lot Size
J Q �hrL1t.1
Frontage
Setbacks Front
Side L: R: L: F R L G,� R'
Rear
Building Height i
2
Building Square Footage
%Open Space: (lot area _
minus building& paved
sk-
arkin
#of Parking Spaces
#of Loading Docks
Fill:
(volume& location)
13. Certification: I hereby certify that the information contained herein is true and accurate to the best of
my knowledge.
Date: �i'S Applicant's Signature
NOTE: Issuance of a zoning permit does not relieve an applicant's burden to comply with all zoning
requirements and obtain all required permits from the Board of Health, Conservation Commission,
Historic and Architectural Boards,Department of Public Works and other applicable permit granting
authorities.
W:\Documents\FORMS\original\Building-Inspector\Zoning-Permit-Application-passive.doc 8/4/2004
File No.
y
9�
ens type or,pri t all information and return this form to the Building
Ins ector's Off c6 v the $15 ding fee (check or money order)payable to the
City ofNorthampton
1. Name"of Applicant:
Address: Oita L`�� Telephone:
2. Owner of Property: 7 J ^ t eA rao rl
Address: C, C OtIg C—e S:t Rc Telephone:
3. Status of Applica/��nt: Owner �_Contract Purchaser n � Lesse/e�, Other (explain)
4. Job Location: Uf ot�d V��f(.{ � ddt,'� "�°'`aDwF
�-
Wqw
. e
5. Existing Use of Structure/Property: L24?'5 C:
6. Description of Proposed-Use/Work/Project/Occupation. (Use additionai sheets if necessary)-:
e 64401t),
7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans
8, Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW ✓ YES 1F 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 Docume #
9.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:_
(Form Continues On Other Side)
i
W;\Documents\FORMS\original\Building-Inspector�Zoning-Permit-Application-passive.doc $/4/2004
File#MP-2005-0131
APPLICANT/CONTACT PERSON BELMORE STEVEN D&DELORES M
ADDRESS/PHONE 41 OLD FERRY RD ()587-0288 Q
PROPERTY LOCATION 41 OLD FERRY (�
MAP 25C PARCEL 249 001 ZONE 1JP, vi,%
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FlIkED OUT
PAZ
ee a
Buildiniz Permit Filled out -
Fee Paid
Typeof Construction: ZPA- 14 X 26 STORAGE SHED
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
INFORMATION PRESFXTED:
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
Se 'c 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
�r
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 the Office of
Planning&Development for more information.