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DEPARTMENT OF BUILDFXG INSPECTIONS /?
INSPECTOR '212 Main Street • MuniciP-11 Building
North,unpton, MA 01060 .
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as i:is/her construction sups. ,,*Fsor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a a e orlvv s�ru
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 r'.egulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footines (before backfill).
sonotube holes (before pour) a rouzh 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 LU ,
--�-
E (fiii �f �a� fl� ilj�ton
rla3aitc3iazrtfa' - --
w DEPARTMENT OP DUI1I�I�G INSPPCTlO1JS = i —
212 Main Strcct Municipal Building
Northampton, Mass, 01060
WOR1CL'IZ'S COi�1TENSA-aO N 1�
.N MSURACE A T A Aq-j-
(li ccnsa'Jperm�tt�)
�LE1 a principal place of businesJresidence at:
(sB-�.tic�ty/sta.tcfa p)
do hereby certify, under tlie.pPjm and penalties of per3ury, lL r
( ) I am an employer providing the folio.ving!worker's compcnsZ�o, cove-gc for Ins
eluptovccs lvorU(lg on Llus job:
i
CL=sur�c Comm y) (Pclic: Nurnir_r) — (i :-pimdcn Dzi`) -
I cat a sole propriccor, general contractor or homeowner (c c;e one) aid hive hired
the coon-actors lined below wbo have the folioVring worker's cat oep_a6on pe!icies:
f --7/Ou
(�tamc o.Co,t ,c.o- nstran-- -� _
c,... Cotnp3n}fl ouci Nfaca--.) (Y:71sdC0 Datc)
- ,C, . �
(NzMc of Coaa-zaor) (Inssranc ComaaativPo!ier `t rncct) (Ek U`z6on Date)
(N.me 01 Co=c-tor) (Insuranc;. CamT=)-/Pouq• Nttmb�r) (Expirl7on Datc)
(Name of Coatraaor) in-sUfa.nC` ComcanylPoucy Numbr r) Txpir-,ioo DaLc).
(nusc'J_d�sC•ocal i'sca.it ate.-,-..•ti.�a�c!v�iat«ma�on pccaiaias to.1J ocor-_c.o:-a) - -
( ) I
am 'a sole-proprietor and have no one worming for me.
( ) I am-a home owner performing all the work myself.
NOTE:pl�_sc be LQMjrt rfi,.Kt�jG hcmra��cn KjOO�=alvy P<_L'Q=w cU�.:.-•,--.,.••- cs c oo c rgaa work oa.d,J1_g of
on(acct t1_ t'ro-Unks is IXEr 4 h the bo=cr-w raider or oa the FJLo6 _tbeen L c roc C_,-U).a.-e-ni�....i i ra be
cixPloycz ua�c t6c K9 �pca A=(GC152.y t(5)).=ppUt�oa by L homraax fc a be=e or p=mg=y c%-idcD=tL-c
I vP1 m_vr ore:a PIoyx under .dru W ocSr ora Compam.lioa Act
t - tad tha a copy of thi.mtcacm o3.y b- Aced=&offioc of t+z urt for th.
�vcxSe�e if Qim ttu to taut �T tmc'e sccion 23A of MGL 152 cw Irk to the i=p=i ion of c•im�Pc .Jlia
coca:y za of a ryas of up to S I}oo.00 undf, of up to woe n=r='d Civil pcw hia is do rum of a Siop Work Ord.and a
firs✓of
::100.00,dsy,pi of me
For dcp++'.mS.J u,c Drily - —
� PCfIIIIi NL:,IDt�
Map Lot ° 3.
�Sit�itur_ efLic=_r :IPcraliuc:.
SECTION.8-CONSTRUCTION'SERVICES c
8.1 Licensed Construction Supervisor. Not Applicable
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
SwRe esterWiwo Pn ca+ei ec 0o tra- _ = `� Not ApplicableN
Company Name Registration um er ---_
Address Expiration Date
Telephone
SECTION 10-WORKERS'COM ENS'AMOIS HNSUt2ANCEAFRlpiotwFEM,6 E-•c 15 ,; 2506}}
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(l) 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-vear 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,Stat7 and Local Zoning Laws and Sta f sachusetts General Laws Annotated.
Homeowner Signature
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SECTION 5--DESCRIPTION OF=PROPOSED WORK(ctreck alkapplicable)
New House ❑ Addition ❑:. Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[O] Other(01
Brief Des criptigqn of Proposed
Work: .9 1,cce- �flf �� �', 7f`�CdflS tal ld 1+� � f r-ec l G(!l� ����
Alteration of existing bedroom Yes_A_No Adding new bedroom Yes _�No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
69ff-ju i�kto rse%ah-cm adct�tia�to exrs r> .: tarn cor>'r�p}e faEC r NI
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. 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 Ta;-OWNERAUTKOR1ZATION TO;_BEGOMPCETEl6 WHEN
OWNERS-AGEN L OFD CO[VTI7�kGTOR iRPPL1E FOklim IL NGPERWT
" as Owner of the subject
property
hereby authorize
to act on my);ehalf, in all matters relative t9 work authorized by this building permit application.
,4- �s--
Signature of Owner Date
a Owh /Authorized
Agent he y declare that the nd information on the foregoing application are true—and accurate,to the best of my knowledge
and bell .
Signej ug6er the pains and pen (ties of p .ury. 7 o
Print Name
Signa ure of Own en Date
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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
s E
Frontage
Setbacks Front
� I
(
Side L:t,�. R: 'L R:
Rear
Building Height
Bldg.Square Footage % — k
Open Space Footage %
(Lot area minus bldg&paved ' 11:
parking)
#of Parldng Spaces
Fill:
iE
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book Page; ! and/or Document#j
B. Does the site contain a brook, body of water or wetlands? NO V DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q Date Issued:
C. Do any signs exist on the property? YES 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 NO
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 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Building Department ~: �Q vie
212 Main Streete+�re
Room 100 ater [" A arl EN
Northampton; MA 01060lefs cturafar
phone 413-587-1240 Fax 413-587-1272 Pfot(S� Par►Sr � "
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
S,ECTION-1. SITE INFORMATIONI
1.1 Property Address: = Th�ssectran to be completed boifr`e tx
Y
/� 'Vane °:OYerlay Distract. '�
( W ►
�ElinSt:I3istrrct
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SECTION 2:-PROPERTI('OWNERSHIP./AUTHORIZED:AGENT=;
2.1 Owner of Record: q F - Ae
14�
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N Current Mailin Add�e�s: ,J
) T 'P$il - j 7a 7
Telephone
Signat re
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION I,-ESTIMATED-CONSTRUCTION COSTS. -
Item - Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building S" O (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) -Check Number 'O
This Section For:Off%ciAr Use':Onl
Date
Building-PermitNumbe r.':' Issued:
Signature:
Building Commissioner/Inspector of Buildings - Date
pe
x`50
ce
a
y �.t
a � ,
Cl'
File#BP-2006-0096
APPLICANT/CONTACT PERSON BOBALA JOHN J&KAREN A
ADDRESS/PHONE 25 OLD FERRY ROAD NORTHAMPTON ()586-2704 O
PROPERTY LOCATION 25 OLD FERRY RD
MAP 25C PARCEL 263 001 ZONE SRAVSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
T_yneof Construction: ERECT GAZEBO
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 PJAESENTED:
Approved V' 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
V°Permit from Conservation Commission Permit from CB Architecture Conunittee
Permit from Elm Street Commission
J
Signature of Building facial 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.