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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 sup(;-,,i 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, C understand the above.
( ome owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date //--C/((—U-3
Address of work
location (Q
- d
-• 6 ��.1�K 55 A C ll I1 r,C t
DEPARTMENT Of' BUIL-DD) G INSPECTIONS
212 Alain Street ' Municipal Buckling
Northampton, Mass. 01060
WORICER'S COMTENI SA TTON INSURANCE ATFMA 17
__---
N:'1111 a principal place, of businesshrts dcnc t:
are
CIO hCI-Cby CCrillti', t1flA 1- t11C l) LAS ilU pCi1 ii1CS Oi 7Cf�Il11� i118i.
( I aS17 an Cnlp!Oyei prOVl(l1lly the iollo`,1inC v,olt;Cr'IS C0mI)Ct1saU0i] GOVC:':'•C 'Or Tny
employees wor4drig on t}Iis job: v
(Insuan� Company) e�c.Number) ---- (FxTir acn Date)
( I am a sole proprietor, y=enPrai c-Ji1�TZC?Cr homcowo (circle Oct) and l:a`.'C tired
the contractors listed beio; foi' ::; , pr C l
1 orit s cot: -o n�a::orl
V oo
(Na tDC Of CO llrlCiGr) ic{ N1 u-lb--r)
(Name of Contractor) -- 7 ts�r]nc Cor _nvfPo!icr \in] r) (1 ?:Girntin Date)
(1,Iame of Coatraclor) (lIl 1r?nCC ( : :,�' PpI;C: I� 1 5,:,-1 Pc,r. Dat2)
- (Name of Contractor) —- JDSZ'Imnc- ComrYiy/Policy NumbLr) - (E):ri-ai(,-- Date)
-
l I (LTl I, sole 111OpIleiUi fill htiVC Il0 OI!' `..'OH-Iii,; 1o1 -1?C.
.l I am a 110I11C o',t1I11'r Ii CI?O"I?11I? it i_' Gi r; iii i`� lf.
NOT&:plc-,c to awuc Llts:'.t
not mccc thJn throw Unit]in lt{`cdj t-�Y I:; �:tt'tiS or O(i'�>`U:._.-._3���,u-;�:�r1 LhcC.o�:c rx:t[;crr;Jh, ;_::c lz h.
ca'.ployc3 u_n.:kr ter«ro:;n'_cam . ^�Act(G" (Si1.r.l:,•._:.:ic::l,y hurl
legal rt tut of an cmployor unur t:In Workc1:t�,i,'•m-,,.lion�.cL .
[and---Tt nd the a COPY of th:x ctatcls'auy bo fotvrnrd j tot; IYSiartax—:of lr.ias:ri.j A �I& I a'Offl—of for tlx
OOv—&C vmfZCtioo and ih.t f_ilurc 10!r 25A of?.iGI.152 can I,-�d to the impasition of cry i:_l pct aL:s
c`0Q1utmg OCa fu)--of up to S I,SW()J n:tom'Y i-:;Irvy Of'.!;)to cn:} :.�civil,rnz2tica in d c Ii,rtn of a sty,`;;c i'-O _rd
fire-of SI0,0.w t day t 7.in:1 mc.
uro oily i
Pcrrnit Numb-:r __—.------'---------�
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S1=CTONB CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Wffl'-' a 'bme mprouemen"t ontracto Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 VIIbRKERS' COMPENSATION 1NSURANCE.AFFIDAVIT(M:Ga.-,c. 152, § 25C(6))
.... ._ � .._ o.
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)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, StattaDd Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature -�/Lf�n.e
SECT�10�1+I ES FAT ON OI P=ROPOSED°WORK check aal a plicabley ,
a. �-.s •• .. .'.. •sr`c.;: amain :�-"�'�... :�!` 5n'"`k.a, .;�$;a.�*�9';�^z`�^i
�wmi.,.,� ...... ... .... rte,. �:...
3�-
New House ❑ Addition ❑ Replacement Windows Alterations) O Roofing ❑
Or Doors O
Accessory Bldg. i DemolitionO New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: G a 'P,
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
as I.e�'�ouse � or a �ition to eXisting��housing;ci�m!e e �efo`I�ow�ng;
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 y
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 Nc
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
SECT OT( {3WGIER�UT JC�RIZAlON'- :0 BE COMPLETED WHEN
OYINERSAGE� 0 CONTRACTQRAPPLIES FOR BUILDING'PERMIT
as Owner of the subject property
hereby authorize to ac; or
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
��� I C✓) l' �y4' f 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
Signa ure 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 b'e filled in by
Building Department
Lot Size A: cl_L4esl
Frontage
Aw
Setbacks Front r
11001 tCtU , 2-O
Side L: R: '.L:Aoo R:?
10
Rear , p
Building Height 1 3 1 20
Bldg. Square Footage % -7
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces d
Fill:
volume&Location)D
A. Has a�Sppecial 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 of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413.587-1240 Fax 413-587.1272 P
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RtNOVATF,,b `DE'f4C 0S4A WE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: ao `� omgl fficel
I� oa :e
s
EIm�StDistrict
„
SECTION 2 - PROPERTY OWN ERSHIP/AUTHOR III.D AGENT
2.1 Owner of Record:
Name(Print) Current Mail ng Address:
Telephone
Signature
2,2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
tECTIONK,3[- ESTIMATEDiCONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use'Only
completed by ermit applicant ;
1. Building g 2- oC) (a) Building Permit Fee
2. Electrical (b) EE:aimated Total Cost of
t DU v Construction.frorn 6
3. Plumbing Irl Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (i + 2 + 3 + 4 + 5) $ b G('O Check Number �
This Section For Official Use Only
Building Permit Number: - Date'Issued:
Signature:
Building CommissionerAmpector.of Buildings, Date
z
I r
File#BP-2004-0549
APPLICANT/CONTACT PERSON KURTIS JONATHAN R&SUZANNE S
ADDRESS/PHONE 569 NORTH FARMS RD '54—)14,9
PROPERTY LOCATION 569 NORTH FARMS RD
MAP 02 PARCEL 020 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinj4 Permit Filled out
Fee Paid off.S •
Typeof Construction: CONSTRUCT 24 X 24 DET GARAGE
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 OWING 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 Stree mmission
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.
I f
569 NORTH FARMS RD BP-2004-0549
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 02-020 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2004-0549
Project# JS-2004-0772
Est.Cost: $25000.00
Fee: $84.60 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 174240.00 Owner: KURTIS JONATHAN R&SUZANNE S
Zoning: RR Applicant: KURTIS JONATHAN R & SUZANNE S
AT. 569 NORTH FARMS RD
Applicant Address: Phone: Insurance:
569 NORTH FARMS RD (413) 586-1168 O
FLORENCEMA01062 ISSUED ON.11114103 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 24 X 24 DET GARAGE
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 11/14/03 0:00:00 2585 $84.60
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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569 NORTH FARMS RD BP-2004-0549
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 02 -020 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0549
Project# JS-2004-0772
Est.Cost: $25000.00
Fee: $84.60 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 174240.00 Owner: KURTIS JONATHAN R& SUZANNE S
Zoning: RR Applicant: KURTIS JONATHAN R & SUZANNE S
Applicant Address: Phone: Insurance:
569 NORTH FARMS RD (413) 586-1168
FLORENCEMA01062 ISSUED ON.11114103 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 24 X 24 DET GARAGE
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:a 1i'
Driveway Final:
Final: Final:
Rough Frame: (51< 7 ,6.0
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: 0 K 7-
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAPPN OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anC Si nature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 11/14/03 0:00:00 2585 $84.60
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo