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DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR 212 Main Street • Municipll Building
Northampton, MA 01060
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 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
1
1'T0
6 61111 o f 171-flialliptoll
d jf1l i S S A C It Sir,C t 19
�y
DEPART NCI OF EUILDDJ G INSPECTIONS
212 Main Street ' Municipal Building
,o
Northampton, Mass. 01060
WORICER'S COMTENSATION INSURANCE A + MAVIT
a principal place. of busirlesslr d nc !.
(StTc°deity i: :lr!P)
Cf0 I1Creby CCrCiI}'; mTI(]c! Cllc P)lills alld pCil It3eJ Oi �Ci�11I�' Lil<:_ -
I am aI] employer providing the iollov.'ir] : "-;C)1-!1-CIS CoII]pc!lsa6m] CO`'Crf:' C for inn
elzl)lovecs woiidiig on this job:
(I==C: Cornp-am') ( c c;.Nunnb r) (r,-,�T,_rdon Date)
j I `m a sole proprietor, general conk or or hot-'ec" oer (circle one) and 'Iave `tared
the. cootr ctors I.Sted be,o,'r ;,to 11l2 „ i}l. '
�OritP,�S COi peIISi Oft ^!iC:cS:
,Z,,Ia c Of('0IIU1Ct0r) (1rlSL�i1C lOIri^?:7"{!�G!1-j NL1SIltCi) �X! :i:'�Oi: Datc)
(Name of Contn cto-j 1,11151^ P.C� CO IJU1�'1'C !lCl ' ill I} (� D: i10�Date)
(Name Of CoIatmclor) (ln;'a7 nco (_7i j;?II.ili'OI;C:1 11SI11r=7} \,:r 0 Date)
(Name of Contractor) —- (Ilzs rand Come Y y"'oli Numb=�) (Expi ::ia~: Dace}
I
l I ILTl l Ole pl-CiMe"uI i':.:1 haV�- ]lo 011t' .•'U!vii tOf 111-
�, 1 ?iIl Ilollle C;Wiler iiCt?orillln all i!1� '�`.'��..: i-",-o 1f'
NO-IT:plc u be a z e tl_z:�-vL•ilc k c<r�o air .�e.:�!r,.;:; tz c. _:�nc�ar::_n c m er:e;;a r• .._..._�«c!!i- e.
not sxre tl n tlssno units in nt dt 1 t l::Z ..tzv rc: s a a;: ::_i z 'rtct_nI Ltx Co e c n.t Lcrtall-v
c ployc�under thr time tY, ; c
ltpl etatus of in czzployor under tun Wozk,Y'a io L;araiion�.cL
I undc_•itand th,:a copy of tlia ct>tc::s r_:,..y 1•,o fa- ivctod to ttr of i:_:+vur?c for tfm
covaxgc vcific::iioo and th_t f_durc to cover_=ut:3c:.c,:'.iot125.k of I.'.GL.152 cw lc_d to tax impos,ti0q,ct c is 1 pall%:=
comizting of a fur_of up to S 1•S .00 n:'.'cr ^:Itrivr,zti:_of u,2 to cr.-}-ti r.:.i civil crult a in dC fc,nn d"Sic-,) ,Jeri.(} x trA a
Lrl-of S 100.00 a day tg.--in-1 Try--
Foe, 11 o«ily
Ji�nat c()f f.iccrc^Jhctnriat: r•
SCION 8 CONSTRUCTION SERVICES
8.1 Licensed Constructions Supervisor: Not Applicable ❑
Name of License Holder ,`7�Lcxio- c�t�
License Number
l0
Address Expiration Date
3"�3
n ture Telephone
Begs a"elf "ors Not Applicable ❑
k e. 99
Company Name Registration Number fill
(VI &-,044,ek
Address Exp ration Date
Telephone 7•-5
SECTION '0VIIORKERS' COMPENSATION INS',URANCE 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...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)fami'.ies
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"homeoNvner" 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
SECT ,ON i [} S R T�lON OFfFR OPOSED VIfORK(check all aoalbca ale,
,iti..a3-R4 .t'DAkMAI�be'�"R' Yaa+S... 'A}A Y' .."�'mr3da aweNx .. .. n __4''.�s&'K«mfl�»wVYari.."ea• Rf.w.
New House O Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. O Demolition❑ New Signs [ ] Decks > idingX Other [ ]
Brief Description of Proposed Work:T=v16+J "t-we, C—Qmh'C, + L f sat
/
Alteration of existing bedroom Yes '>(,/_No Adding new bedroom - Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
M . xew ou ea nd o. dd"itron to-exrsting ousian''g compEe.:e he followin
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. bimensions
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
SECIOT�� 1NN�RAi1� ORIZA7-ION TO BE COMPLETED WHEN
OWNEFS ADENOCONTRICTOR=APPLIE5 FOR BUILDING PERM17
as Owner of the subject property
hereby authorize t���/— "C & to act on
m half, i all m ers r lati e to work authorized by th S building permit application.
Si u o Own r Date // 4 1 4
to,. 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 ame
— yo _a3
Si re of Owner/Agent Date
t
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 X 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:
City-Qf Northampton
8utid ng Department
212 Main Street
Room 100
v(J"I 2 0 ,Northampton, MA 01060
phone 413.587'<1240 Fax 413-587-1272 1
-----APPL+CAT1.ON TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE IN,FOI?MATION
This secti"n tob', omp etedbyo'ffrce �
1.1 Property Address:
y
,Ma � k
70 ip lyewl
M
�'�) Zone � Ov rla tstr -
str �
W W3
EImSt Diict ��
.. mss, ... ....
SECTION 2- PROPERTY-OWNERSHIP/AUTHORIZED AGENT.
2.1 Owner of Record:
Name Current Mailing Address:
Telephone
Sign e -
2.2 Authorized A ent: `
1-1 I
Nam (Print) Current Mailing Address:
Sig Nature Telephone _.
SECTi0N_3. ESTIMATED CONSTRUCTION
Item Estimated Cost(Dollars) to be Official Use Drily
completed by ermit applicant
1. Building $35-6 - 6 0 (a) Building Permit Fee
2. Elec.rical (b) zstimated 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:
Date
Building Commissioner/Inspector of Buildings
File#BP-2004-0631
APPLICANT/CONTACT PERSON GERALD ARCHAMBAULT
ADDRESS/PHONE 171 WEST ST W HATFIELD (413)247-5903
PROPERTY LOCATION 690 RYAN RD
MAP 28 PARCEL 021 001 ZONE SR
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: INSTAL REPLACEMENT WINDOWS/DOORS,SIDING&REPLACE EXISTING 2
LANDINGS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 010788
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF91CMATION 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 ZL,4�t Commission
20 lao�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.
690 RYAN RD BP-2004-0631
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 28-021 CITY OF NORTHAMPTON
Lot: -001
Permit: BUlidinQ
Category: BUILDING PERMIT
Permit# BP-2004-0631
Project# IS-2004-0890
Est.Cost: $3500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: GERALD ARCHAMBAULT 010788
Lot Size(sq.ft.): 36633.96 Owner: HOULE SHAWN
Zoning: SR Applicant: GERALD ARCHAMBAULT
AT: 690 RYAN RD
Applicant Address: Phone: Insurance:
171 WEST ST (413) 247-5903 Workers
Compensation
W HATFIELDMA01088 ISSUED ON:11120103 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT
WINDOWS/DOORS,SIDING & REPLACE EXISTING 2 LANDINGS
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 11/20/03 0:00:00 394 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo