17C-033 (3) ¢'t t►AAl PJ.
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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 iu.is/her construction super, 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 backfiIl),
sonotube holes (before pour), a rou;Ih 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.
Tf 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
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 `t'j
��c�c��ce ` rUtfA
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A 'qZas.xrtlncctlai - s
o DEPARTMENT OF BU1LDD�c INSPECTION'S
212 Main Strcct 2funicipal Building
Northampton, ATass. 01060
WORIC ER'S COYTENSA TTON ON SUR.-I_NCE AFFMAVI-l'
(ll cc->LC.:,Jper-rnI lice)
%",ILb z prMi cipa-I place of busioess/residence zt:
(stz ticity/sta.tc/rip)
do hereby certify, under the pains and penzlties of perJu-ry, 121
( ) I am an employer providing dic foUowint worku's coinonszt;o, covuag.c Ior Inv
emptovees worljng on oils job:
(Policy ?3,Lmb-cr) -- (E:-pirzuon Dpi-)
�/aim a sole proprietor, general contractor or homeowner (c cie one) and hzve hired
the conuaCprs listed below crho h2ve the fo[lo%vine workers com:)enczdon pokies:
lL+lirilC 0, co:'nclo') compan)•/I.Pouci NI=h1 _:) 1111c)
(Name Of COnQaclor) (bislfanez ComDa2vipo!.ie; "';U0brr) (Expir,.6oa Date)
(Name of Colinacto,) CLasurance Company/pol c}- Number) (Expiry doo Date)
(h`ame of Contractor) 9Msu=c_- Comraay/Policy Numbs) (Expiration D"ac).
(anach:dai-o=J rxc.ifncc+N.in anc!ud_inf'ra oo P'rL. ias to all cua-_ca:�) j
r
{ ) I a sole proprietor and bave no one wor}dDg for me.
.a home owner performing all Lbe work myself.
NOTE:pl=sc be ew-zm th••kIjc bcmeovvcn l bO o=play pezoos w do -.
cs�.•r�oo�rcPac•••orz oa L d.•cll^;,of
tux mocc tlLo tlrnr_tt3rz in u�D6 the botnoowoc-raids oc cc the go.a z;purLca=tbe-eo c-c ooe C=>—Dy eccs_d-ol to be
ci>ployc-3 11 —=;> c.Act(GL!S2=t(5)1:ppticsDoo by a bomcoavc far:lice:cc pans n_y c idmcc the
IcS2!rt_ of dro Workal.Campem.tioo Act
f uadcn�d d'e x oopy of Chia m'=m.y be foe xn+ded to tbo Dcpnrtmcat of Inislid Al &ccaY OtTio or 4au�oc+for the
co—cc vciGc=Ioc A d at-_t L-ih=t to seeur oovRy�ur�dcl soe cps 25A of MOL 15-2 ern Iad to the iposi6m of e- xiarl P-115a
comis,izig of a tine or up to 51_50o.00 and/or jmFQ'isoomc=�d or up to ooc yr3r and ci�i)pm.Y,ia is do form o(a Stop Wort Or&- and n
rr>b 0(:S 100.00 t day.pinu dDG
For&""_•j u.c only .
Permit Number _
Lot "
Siga.Ittrzr otLipccmittcc �' J
Li
cl 7
(c,tv vac-C
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
kRec[este redl�omeiaaaprerraentGoitracfor MME
Company Name Registration Number
Address Expiration Date
Telephone
SECTI.ON,10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L_c.1°52,
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...... ❑
)ill M
The current exemption for"homeowners"was extended to inchide 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 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
SECTION 5-DESCRIPTION=OF'PROPOSED WORK_(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. IZ- Demolition ❑ New Signs [E:3] Decks [p Siding[0] Other[0]
Brief Description of Proposed i
Work: ♦y e� p� `�� �X
Alteration of existing bedroom Yes_ No Adding new bedroom Yes �4 No
Attached Narrative Renovating unfinished basement Yes c No
Plans Attached Roll -Sheet
sa�l�l�few �io"use�a�' �t�d�tion.,t�0�•exrs`fin'a��ousrn -orrrtxf�e' et�r €o�o�nc�na:
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 AUTI-rORIZATION TO-BE COMPLETED WHEN
QWNERS.AGENTOR'`CON'TRAGTOR;APPLIES FOR;BUILDING PERMIT
as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
�1/1rMQNU` as Owner/Authorized
Agent here-by 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.
_ (!/I���iCt v� 411�i��cLt c i
Print Name
C�
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
Setbacks Front il—10
Rear
Building Height
Bldg. Square Footage
Open Space Footage 7 %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Varunoe/Fi nding ever been hsuodfor/on the site?
�3
NO �~��/ DON7KNOW Y[5 x_��
�
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry ofDeeds?
NO � ] DON7 VV KNO YES^�
IF YES: enter Book | | Page, and/or Document#| �
��
B. Does the site contain a brook, body of water or wetlands? NO (5,-
�/ DON7 KNOW v.--) yL5
IF YES, has permit been or need tubo obtained from the Conservation Commission?
Needs uubeobtained /~� Obtained �~\ Date
�_/ �_^ '
��
C. Do any signs exist on the prope�y? YES �_� NO
IF YES' describe size, type and location: i
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradinexcavation, nrfi/|ing)over 1 acre orioit part nfo common plan
that will disturb over 1acre? YES NO [��e
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
t AF
City of Northampton ;taus of Perms# 4
wilding Department
212 Main Street e �e rarlaw � ��
WVW
2 p6 ' Room 100
�v Northampton, MA 01060 X05 tso Pates ` F
phon�3 5- 87-1240 Fax 413-587-1272 PII art };: a �` •
.,
PPLICAT4 N TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -;SITE INFORMATION `
1.1 Property Address: th �� ThiS;sectaon tabe`complefed byvoffu;e
9-1
1J L'V�r��Jlc S+. F is rev.c� Map x Lot rUmit
Zone .� 5 � -•Overlay�t3►stnct
SECTION.2-'PROPER TY`OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
(� y c.-a-� 9-1 N : rA.,.aL S-A ;710 rcvLce
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: '
Name(Print) Current Mailing Address:
Signature Telephone
SECTION.3,-ESTIMATEDZONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b --ermit-a- licant -
1. Building 2 v (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 d `
This Section-For Official'Use-Only
:'Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2007-0568
APPLICANT/CONTACT PERSON KAHRMANN WILLIAM&ANGELA M
ADDRESS/PHONE 97 NORTH MAPLE ST FLORENCE Q 585-1586 Q
PROPERTY LOCATION 97 NORTH MAPLE ST
MAP 17C PARCEL 033 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction: ERECY 8 X 18 SHED
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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 Stre ommission
Signature of ui ing fficia 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.
97 NORTH MAPLE ST BP-2007-0568
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-033 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2007-0568
Project# JS-2007-000823
Est.Cost: $3500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 22869.00 Owner: KAHRMANN WILLIAM&ANGELA M
Zoning_URB Applicant: KAHRMANN WILLIAM & ANGELA M
AT. 97 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
97 NORTH MAPLE ST O 585-1586 O
FLORENCEMA01062 ISSUED ON:121712006 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 8 X 18 SHED
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 si nature:
FeeType• Date Paid: Amount:
Building 12/7/2006 0:00:00 $25.001170
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
EW
3_ '
97 NORTH MAPLE ST BP-2007-0568
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-033 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2007-0568
Project# JS-2007-000823
Est.Cost: $3500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 22869.00 Owner: KAHRMANN WILLIAM&ANGELA M
Zoning:URB Applicant: KAH,4A_ W1
AT. 97 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
97 NORTH MAPLE ST 0585-1586 Q
FLORENCEMA01062 ISSUED ON:121712006 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECT 8 X 18 SHED
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•.rtlF B OrC p J 0 C a
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc si nature: G '
FeeType: Date Paid: Amount:
Building 12/712006 0:00:00 $25.001170
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo