28-002 (2) X0.0 ..
gttlP).
o�`e Gxty of Wartt ampton
� �1Glassxchicseffs � - _
c� DEPARTMENT OF BUILDD�,'G INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '>o
Northampton, MA 01060 s
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sups: • sor. The stare 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
F= yE (rii of �nrfljilllt�Jf01t
�la3 inch nzrlla, _
DEPARTMENT OP BUILZ)TNC INSPPGT10J.rS
212 Main Strcct Tfunicipal Building
Northampton, A1ass. 01060
1
i
WO Ma, I Z'S C O l2P EN S ATIO N 17NS TJ A_N CF A FTID A VI-l'
i ,
(liccvsxJpertn�ttcc) _ --
with a pfMi cipaJ place of business/residencc at:
O X (,t(c? (d/iAAf Z-- : AA, ,A-
I (s>�t/city/statrla p)
do hereby certify, under the.pami and penalties of per3ury; aI
( ) I rn an employer providing the followinL worker's comncnsabo, cove age i0r in)
employees «vorlong on this job:
(Insursn=Company) (PoLic: Nu_• �_r) -- (1 :-pinion DzL.)
(- I
aim a sole proprietor, general contractor or homeowoer (ci cie one) and have hired
the eoatractors iiste-d below wbo hive the foll0«r1nQ worker's co_oensa 'on policies:
5,
Oc Cont^aor) (InSLr31)C; COTnoarI)'/hGUC-; Datc)
i
I
(Name of Contraor) flns-w7anc:. Compaavi?o!ic- \umcrr) (Exvir -bon Date)
(Name of Connacto,) (Insurance Com�ao)/Pol;c� t+rstu) (Expirdos Date)
(Name of Cooaactar) la=urancc Comraay/Poficy Numb r) kT—. aaon Daly).
(atIaGb=d 5o�.1 rSca.ifo—c ,to iaforn.:ioo pctaiaitts
to
I am a sole proprietor and have no one worming for me.
( ) I am-a home owner performing all the work myself.
NOTE:plcsc)x ea xtc th,. +4 le bemcowacn wbo anploy pczo¢t to t50_ o, r rcpxu..-oric d--U—,-Z of
tux moot they U=,D--=nj is u'Jicb the bomrrn+vcr rexido or co the Qouac},1971rtc+•=the-=«oot C=am--_Vy ooerider to be
employes uncle the.0--is{= An(GLI 52-=1(5)�=;>pU=L600 by a bommave fcr-Ge e cc pemit zy e%-rdenx tLc
1c-Sxl n,,,,of=-=Ployer uoder duo Wockc ,.Coc=p o Lioa.Aar
[uodaitand th a a Dopy oC thu mtemcat may be for xnrded to the po�of 1nd+Tlie1 A—d.=&Offioo or 4—u.00a foe tha
ooveaGc vaZc=ioo and th:t U c to soc uz boverase under=C:ioa 25A of MGL 152 rin Ied to the i�—of ei-in pCn -
coo=Lvjs or rrnc orup to s130o.00 andlor orup to ooc)c =d o�u pmaY.ia in the roan Ora stop Woric Order and a
ri=of S 100.00 r day aPina mC
For a�.rt�-=ter ux only
� Permit 1�tuml
� x�
_ +
LAt
Si 1 01 L10=nScC/Pcrrru Ucc
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
GtG 014 1 oq
J Addr s Expiration Date
Signa ®rVc-' Telephone
Reg>steredNoiviinpro�rernentt'sontraco - - �' Not Applicable .❑
Company Name Registration Number
130397
Address (( Expiration Date
PO 0� 0 S3 Telephone&�S
SECTION 10 WORKERS'COMPENSATION INSURANCE iAFFIDAVIT(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...... ❑
XA
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 Gkp I La s tated*,yJu may be liabl or erso
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 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0] Other[
Brief Description of Proposed
l'TcoN oi x3t 2`t L
Work: `tLcK i— P A
Alteration of existing bedroom Yes_ No Adding new bedroom Yes �_No
Attached Narrative Renovating unfinished basement Yes --2( No
Plans Attached Roll -Sheet
sa e�l'otxs rt rI` Mid'4656Ms�IlYq tioCySil7q. Omp a e. ;e o �utrinc�;
a. Use of building: One Family X Two Family Other
b. Number of rooms in each family unit: S Number of Bathrooms
c. Is there a garage attached? JW
d. Proposed Square footage of new construction. A//,�A, Dimensions IV 14
e. Number of stories? i
f. Method of heating? 0,L, '7BW b�'' � Fireplaces or Woodstoves Number of each
ff
g. Energy Conservation Compliance. AJ Masscheck Energy Compliance form attached?
h. Type of coistruction
i. Is construction within 100 ft.of wetlands? Yes _No. Is construction within 100 yr. floodplain Yes_J�-No
r
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? K Yes No.
I. Septic Tank City Sewer X Private well City water Supply
SECTION 7a=OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENTOR'CONTRACTOR:•APPLIES.FOR..BUILDING PERMIT
I '��� P A e —� as Owner of the subject
property
hereby authorize Tm\e�, S-)
to act on my behalf in all matters relative to work a horized by this building permit application.
i ature of Owner Date (�
I ��1'If`n�°�3 S 013A- 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.
-3'-' 2 ss
Print Name
Signature o g Date
. V
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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
Side L:7,2,0
Rear !'job
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
-
A. Has u Special Pennit/Vahanca/Findingmverbeenisyuedfbc/unthasite?
�� � N
NO �~� DON7KNOVV YES v���
�
IF YES, date issued:!
IF YES: Was the permit recorded atthe.Registry ofDeeds? '
NO x—�
DON7 KNOW 0 YES
IF YES: enter Book Page' and/or Document#|
'
�� ��
B. Does the site contain a brook, body of water u,wetlands? NO ��' DON7KNOVV x�� YES v��
,
IF YES' has a permit been or need to be obtained from the Conservation Commission?
Needs umbmobtaloed �~� Qbtainmd �~_�� Data |eoued.'
�~� � ' .
C. Do any signs exist on the property ��� Y[3 �_� NO
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,gradingexcavation,or filling)over 1 acre oriod part zio common plan
that will disturb over 1acre? YE8K � NO �/3
� "~� ��'
|F YES,then o Northampton Storm Water Management Permit from the DPW is required.
City of Northampton Cis 'iti�r �
wilding Department
212 Main Street
Room 100
Northampton MA 01060 e `
" phortp 4'1.3 87-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1�-SITE INFORMATION
r This sectigr>rto�e completed try6off1-
1.1 Property Address: d
4 1 Z (E2
S" Ives �� iena t
,g'
Overlay Duct
m�joN
E�a,.St DastGft� `r C�t}isfnct "
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Na a(P- t) Current Mailing A ress:
•
Telephone
gnature
2.2 Authorized Agent:
Po T,��'(I MA- 414-D ICE S3
Nam 1(Print) Current Mailing Address:
Sign ture Telephone
SEC <ION-13-ESTIMATED CONSTRUCTION COSTS,-
Item Estimated Cost(Dollars)to be Official Use Only
-
completed by ermit applicant
1. Building ^ -(a)BuildingPermit Fee
2. Electrical I {b)Estimated.Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=0 +2+3+4+5) Check Number
This.Section For Official Use Only
Building Permit Number.. Date
..Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2007-0175
APPLICANT/CONTACT PERSON JDR BUILDERS
ADDRESS/PHONE P O BOX 66 WHATELY (413)665-7587
PROPERTY LOCATION 412 SYLVESTER RD
MAP 28 PARCEL 002 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 444.0 0Q
Fee Paid Q,Z2
Typeof Construction: REPAIR BLOCK FOUNDATION
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License 074104
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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
Permi Elm Street C ssion
2 d
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.
BP-2007-0175
GIS#: COMMONWEALTH OF MASSACHUSETTS
a" CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2007-0175
Project# JS-2007-000265
Est. Cost: $2700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin JDR BUILDERS 074104
Lot Size(sq. ft.): 37505.16 Owner: VACCHELLI ANGELO J&BARBARA A
Zoning: RR Applicant: JDR BUILDERS
AT. 412 SYLVESTER RD
Applicant Address: Phone: Insurance:
P O BOX 66 (413) 665-7587
W HATE LYMA01093-0066 ISSUED ON:811612006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR BLOCK FOUNDATION
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 8/16/2006 0:00:00 $25.002373
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
412 SYLVESTER RD BP-2007-0175
GIs#: COMMONWEALTH OF MASSACHUSETTS
MapBlock: 28-002 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Cate o : BUILDING PERMIT
Permit# BP-2007-0175
Project# JS-2007-000265
Est.Cost: $2700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groun:_ JDR BUILDERS 074104
Lot Size(sq ft.): 37505.16 Owner: VACCHELLI ANGELO J&BARBARA A
Zoning; RR Applicant: JDR BUILDERS
A_ T. 412 SYL VESTER RD
ApplicantAdtiress=
P O BOX 66 7
W HATE LYMA01093-0066 ISSUED ON:811612006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR BLOCK FOUNDATION
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector (if Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Finn Final:
Rough Frame:
G,i:,: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation: DAL-
,.:.;.. Final:O H
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. gle
Certificate of Occu anc si nature:
FeeTVpe• Date Paid: Amount:
Building 8/16/2006 0:00:00 $25.002373
212 Main Street,Phone(4 13)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo