17B-023 (3) p4"�x�PTO
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
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 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),
s_onotube holes (before hour), 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.
< (Hom wner/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 wor
location
$ - 6 ��cssxtllnsttis' � —
DEPARTMEl",T OI' DUILDDI G INSPECTIONS
212 Maul Street ' Municipal BUIUng
Northampton, Afass. 01060 ,
WORKER'S CON1TE tTSATION MSURANCE AFFED .VIT
i uD �t-�►
%vlth a principal place, of bustness/re:ttyenc
i! le Q0c.K Lot-111 6 R FS 1J i14,A- P (pl c nc'=; ��Sb LI 3Y7
do hereby CerLly, l!I]C'cl tilt-' 1) li]J :'.ii4 peil !t1CS Oi pC;I�illlt, '.[lH::
O I am an e:iapioyel- providing tilt- o110,,,nc, •. -orr_crs cornpcnsation coy+era s or Illy
employees working on this job:
(Ins=C-I Coclpam,) J (,Pe t-,Numlxr) ----- "r} ir.:iien Date)
I am a sole proprietor, genera ccu ac`cr nor,_co11Vne: (circle one) and lured
the contractors Listed beiov ;, o h-, the `oilr orzLe s ccmml nGa. on
R"'a c Of CO 1L'-Ictcr) �nSJ :)CC Ot?:D.'.:i'r'TG(1C{ Zvr lSTl :) �:'', `C: C': Dale)
(Name of Con m nmor) -- ciasur,_nce Corr!ran, 1po!icr Nlribcr; (l :o; nn Date)
(ir'ame of Contractor) (IAS ai1C (_Ou "'_n.i/�O�;C. NUJIIti_i) , '.ti, �m+Q Date)
- (Name of Contractor) —- (1aa,.raiic---Com- y/l'obcr Numtr-r) (I xri are.- Date)
(^ttl4'1:.{��S::C,(:�1 S::'_.....-_... .:7 ..:_..�... ....'K:..•..,n. �- ._.... � Ali::t:::.......-.1
1 zum it „Olc pvc.j 1L''�Or 2111 [lS'v i?O OP'� .,'l;?h�iit' tot M-''-
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NO"I�::please be ns.-uc ti�st•.�=:ilc fx�r,ca:~zr_-c:':,�<-_--1,!�;�Ir;::-���i.�;;�c-':_aac4 a:::_ra:.im ca:c,:ai:.: ..__.._ :�ct!i::,a.
not uKcc tha throo units in%%i--di uFx f .y±:sz, r u a; ` •_..:s z ur cc n2 LhcC.c a�rxt crap_ o_r::::(:: h
cV.ploy=uti'. tlr_wt-,-,r _mrX.--.__.cc -C,(G i.'.52 1(5); :t: ._..,it-: +y a hn-ncou-.sa:cr_ cc c cc
lcgxl ctatua of an cmployor un+:cr tires We kc1a Co »rrr,tion!.cc
I unde-st. d till a co-,y of thu, ctatcls_',evy bo fcnWxutloJ to tba I}Ytnrt-x�cnt of 1oaLL;:riJ- A,66d s'CiFoo of +r =a for Lx
covert vciscalioo Attd that f_il=to: :co��r ut -: cC.ic^25A of?.iGL 152 can lc--J to tlx im1 os tia oI c ^r_1 Pte -
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aria$of a ff o�yp-to'3t� J.C�J a:t-'-'cr c-:+ -.1 of::p to cr.:}�-.. ....j evil lxcultics in tc:cnn cf n S:r.,+`;•''c*i:�}ti= ..
fm oCS100 fey i aitt:t m
.r` For dq:.:uxrxtal urc cri3y i
+ L S � 1�eS Inll 1�ttiIltY.=f �
Sit;Imturcof;.icea:cJI'r.rnt,etc.
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SI=CT30N 8r-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 'PAU I f) c—, L-P,4-1
License Number
i 1 16 rZ0 [,K L ktJ o S`S
Address Expiration Dale
IV 04
Signatu Telephone
S 8 13 q?
� Re"" isf�ered orn`e mpro emen Gont actor - Not Applicable 0
Company Name Registration Number
i ^
Address Expiration Date
Telephone
SECTION IQ WORKERS'COMPENSATION INSURANCE-AFFIDAVIT(M.G.1 c. 152, § 25C(6))
orkers 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 Dwelling's 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 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
v'
y.
SECT IONaDESCR.OTCON OFPROPOSED WORK(check all applica'b`le)
ROM
New House ❑ Addition ❑ Replacemgnt indows Alteration(s) ❑ Roofing
Or Doors Q�
Accessory Bldg. ❑ Demolition[] New Signs [ j Decks [ ] Sidings Other [ ]
Brief Description of Proposed Work: RZQ?riR l i�`x�'n GARR��. R�=r" �Pi a�a Po ch SASrI� 5 WNCI bF1Ly'
vv �
t ti .5�ii�+
Alteration of existing bedroom Yes �` No "Adding new bedroom Yes No YJ be
Attached Narrative 0 r Renovating unfinished basement Yes No
Plans,Attached Roll 0 - Sheet 0
a fig°ewe=ho ld or a°diiit�on to',.existing=hoirsrng;comp e�`eeRWIol=lowing ` No C+i4pces Td
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. 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 .
Septic Tank City Sewer Private well City water Supply
SECTION �aYVNERAl7THORIZATION TO BE COMPLETED:WHEN
AWNERSAGEN70(tCONTRACTOR APPLIES FOR BUILDING PERMIT'
1 E L I Z i<I^N 0 t2 y r as Owner of the subject property
hereby authorize Nv►D CL to act on
my behalf, in all matters relative to work authorized by this building permit application.
Sign ure of Owner Date
Aw✓# p G tAQK as Owner/, uthorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the e
knowledge and belief.
tr the pain anal penalties of perjury.
Signature if Owner/Agent Date
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 x DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT 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:
N
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C, •.y�" "
City of Northamptonw
1-npton,ing Department
,.
2 Main Street u �
Room 100 2 2004 N` MA 010605
F phone 410-W-1240-1240 Fax 413-587-1272 t?t m
ARF .ICATIdN-i6iE AgMtWT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address:
This secfion to be completed.by office
7 8 q>p k c,, la Nla� Lot brut
Zone '.Overlay District
r
Eim St.4Dist[tct CiB District
SECTION'2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
A-391),A-391),Tlfi/f M Q r 0�✓ ,a � t�e.,,
4!t, pt Telephone 3 rj/ 7 yep
Signature
2.2 Authorized Agent:
Name(Prin Current Mailing Address:
Signature o Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit @pplicant
1. Building '(a) Building Permit Fee
Re I wl?? ►)3
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) 2 5-Do -Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
471 BRIDGE RD BP-2004-1224
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17B-023 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinci DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit# BP-2004-1224
Project# 35-2004-1864
Est. Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 21387.96 Owner: KENDREW JOHN F&ELIZABETH A
Zoning:URB Applicant: KENDREW JOHN F & ELIZABETH A
AT: 471 BRIDGE RD
Applicant Address: Phone: Insurance:
19 SHEFFIELD LN
FLORENCEMA01062 ISSUED ON.613104 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS, REPAIR
GARAGE ROOF & REPLACE SIDING AROUND NEW WINDOWS
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 6/3/04 0:00:00 3810 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo