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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal 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 has/her construction supe_ :1sor. 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
ade
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
i ��tw•rp�
0 0
F} yti (yif� of �nrflj �)t}�fol) _
9 J E ��asaRrhncrlle'
a DEPARTMENT OP DUILDr)\,G INSPPCT10t.'S - —
212 Alain Street Municipal Dudd;ng
?Northampton, Mass. 01060
i
�N'O RICE IZ'S COIITENSATION MSURANCF A17FMAVIT
1
(liccnsxJ{xrm�ticc)
\%Iith a pri,-icipal place of business/residencc at!
do hereby certify, under tic-paint and penalties of per'uj-y hit
( ) I am an employer providing the followimz uvorkct's cotnocnsZdo, cove age for lay
employees wor.ong on this job:
(Insunn� Conte') (Polic: FE-xpirz on Dom)
O I am a sole proprietor, general contractor or homeowner (c C,- one) and have hired
the consactors Listed below vqbo hive the following worker's cai oenc2aon pokiest
i
(Namc Oi Conrmcwr) (InstrJnt COIIlDI�1)'!l�GUCi ��'L1n1LC:) -`:J1iJlQ I��LC)
(Name of Cootraor) (Insurance Comanyipo!ic-; \umjccr) --,D-
Lr
-lion Date)
(Name of Connaao;) (Insuraacz- Compan)•/Poke}• NumbJ) (Expirraoa Date)
i
(Name of Contractor) (Lasziranc�! Comcauy/POUCY Numlys) (Expi-,6oa Datt).
(nt33r,��dio'oca!bc�,it nccra..1•to ctcudc iarorn,.a oa pctaiains w.17 oo�-r o:•�) .
( ) I am 'a sole proprietor and have no one work-ing for me.
I atzt..a home owner perforTning all the work myself
NOTE:pl=se>x ecrare t� "kale bemcu.�vcra w oo employ P--zozu to eio cr r�ro cr rc,•nu Work oa.d- U_.r of
ovt morn tb--D 't..r.r.tmij is«b3e6 tbt bomoovmcr raid=or oa the p-ounr..,zgparten:_-a tbecn w=.daod to be
c�ioycz ttnc e the..ui�3 or yen Aa(GLl SZn 1 CS)) =PDtinciw by n 6om�avc fcr_l;ez.a pane r=y--ids«tL-
IcPJ rtaau of to<rPloyar under dw Workcet C.00apoo3a o Aee_
f undcs:aad tha a Dopy o(thi.mrcmcaz may ba fory w ded to rba pcgorcmcat of]oA�zrr;J nccidcma OS.00 o(lra.r•non for Lt.
covcr�c v+ciratioo 4-,d Uzez L-ilta•e to so=urs tovcrx Und loecica 2SA of htOL!52 era led to the LzrPosaioa of eimia;d prnaJti(=
coasisixxg
or,Ciao ortp to S 1 Soo.00 arldror>79�typ® of up to Doc yc tad cN-U pmahio io the form of a Stop Work Ord-aad a
ru=or 5100.00 a d:y Lpm:a ED,-
For:.��,••�.'u,c aril y
Pcrmit Numb=
Lot "
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
Not Applicable .❑
S Rea;stared 1466e161y ro
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 � orri Q r� emi 0
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-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 buildine 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 d Local Zoning Laa and Sta e o husetts General Laws Annotated.
Homeowner Signature
SECTION 5-:DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition [] Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [92r Siding[0] Other[CI]
Brief DescriptioA,,qof Proposed t i1
Work: •� ' - ' c e. i,✓ -�— I o�
Alteration of existing bedroom Yes �/No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
g r,a m .. ens s t cT �...� ,�'a*„„'a�Ct A� a.5.a. ,�m73�, .�ns*++sc
A:1 New�`hbrrlse and or aCditl''' bkisffhd lh6q ffid comy ete theYfot owing:
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
L 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 7a-OWNER AUTHORIZATION-TO BE COMPLETED.WHEN
OWNERS AGENT''QR CONTRACTOR,APPLIES FOR.BUILDINGPERMIT_
n f
as Owner of the subject
property
hereby authorize
to act on m behalf, in afters r o work authorized by this building permit application.
C
Ll
Signature of Owner Date
1, 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. 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 µ �
Setbacks Front
Side L: R:� L: R:` (
Rear Awl
Building Height
Bldg. Square Footage %
Open Space Footage %
Lot area minus bldg& aved �€ {
C g P
arkin
#of Parking Spaces
Fill:
volume&Location
A. Has a Spe ial Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page" and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
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 0 NO e�
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 1 NO Q
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 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
a,
City of Northampton ��
A Department
�—,Building,� 212 Main Street t
Room 100
,��(�, N ampton, MA 01060
�o� 2 pine 413-587-1240 Fax 413-587-1272 'F x
1
_APPLICATION(", 9AILJCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This secttan to be compfefed b y office
rc k
z Mai dot Unrt
J Zone Overfayi3estrfct
-
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
V?L&A4 �1�
Name(Print) �— Current Mailing Address:
Ax,-�J 244
_ - Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b).'Estimated`Total Costof
Construction from 6
3. Plumbing Building'Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) j Check Number
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2006,-1147 ,
APPLICANT/CONTACT PERSON PAYNE ANDREW C&
ADDRESS/PHONE 470 BRIDGE RD FLORENCE O 584-1686 O
PROPERTY LOCATION 470 BRIDGE RD
MAP 17B PARCEL 006 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 24 X 14 DECK
New Construction
Non Structural interior renovations
Addition to Existinp-
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE Ff�LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN��ORMATION 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 ssion
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.
47,0 BRMGE RD BP-2006-1147
G1S#: COMMONWEALTH OF MASSACHUSETTS
Ma ° . 0 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2006-1147
Project# JS-2006-1697
Est.Cost: $3000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin Homeowner as Contractor
Lot Size(sg.ft.): 74052.00 Owner: PAYNE ANDREW C&
Zoning:RR Applicant: PAYNE ANDREW C &
AT: 470 BRIDGE RD
Applicant Address: Phone: Insurance:
470 BRIDGE RD O 584-1686 (�
FLORENCEMA01062 ISSUED ON.51512006 0.00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 24 X 14 DECK
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 5/5/2006 0:00:00 $50.001753
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo