17C-071 (3) 6
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Nortli unpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to
act as its/het- construction sup,:: �-isor. 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 o per/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date /p
Address of work
location
O O -_..
�Zas+nrhnsrita-
I
Uri I ]a' "artliumpicii
o DEPARTMENT OP DUILDFNG INSPECTIONS
212 Train Strcct Municipal Building
Northampton, Nfass. 01060
1
«rOIUCER'S CONICENSA`nON GNSUTtA.,NCE Al=, AVIT
(Ii cMLCC/Pcrmi((cc)
vqiLb a plzrtcipal place of busine,—!*c;idence at:
(Sa=t/ci tylgaicJa P)
4 do hereby certify, under the.paint end penalties of peOury; h:t
( ) I am an employer providing the followine %porker's comocnsaz ion covemgc for Iny
etuployces wortog on uus job:
i
(Insur-� Conp:cy) (Polio:?-u--zbcr) -- (r':-pinion Duo)
i
( } I an a sole proprietor, geaeral contractor or horneowDer (ciFc;e one) and have hired
the cona-actprs listed below wbo have the worker's cam:)ensadon pckies:
(Name Of Co`tr cior) (In urancc Compa,i)vi'cGc- �rL1IIlCG:) ii-X)t:'� ^ l�ltC)
it
(N me of Conmc ior) (Lrsuz.nc;. Comoaa,;RoUc- Nuzec_r) (-Expi-z ion Date)
(Name of Coarma o,-) (Lasuraacc ComT=)-/PoL-q- Number) (Expirzdoo Date)
(N=c of Connector) gnsuraac Comeaay/PoUcy Number) (E��iniioa Darr).
(atu.:b:ddi�ocal rScct.iFacoex,ry to ate'ud;iaformaIIoa penninin6 to all am-�ers) -
( } I am a sole proprietor and have no one working for me.
{ I am,a home owner performing all Lbe work myself.
NOTE--pl=_=Ix exire tb.r_w't_}C bemNµaCY1 w'b0 c=ply pczooa or rt,air--ork an.d..cll-F of
oat morn tb=ttsr_tars is wzzch the bamoc.�me=raids oc oa the U-oua6 zppurteass tbcea oees:dzead to be
c-ploy--u---the..-k&z o r==xoa Ac:(G LI 52-=1(5)�r wd=.6on by a bomeoavc for_6c=-_x or permit r=y c%-rd=o=EL�
Icg�.!cti'uc of ea exployer uadcr t1w W orfr.cle(,ompeimatioa Ad
I uodcrz+ad dxA x copy of Chia cmt w-.t may t u for-s.urdnd to the paper mmr of Indisrial nccde.&OIL--f L-'^°oa for the
oova�e Y=Zc=1100 a--td th1 GJ=c to scs3irc torcrabc under seeaioa 25A of MOL 152 m Sod to the iaxposixioa of cimixw peailtia
000si!=S of a fiat of up to S S 300.00 and/(r or up to ooc y=r e,d M)pm+ltia s It"form of a Siop Work Order azd
rim of s 1 00.00 d_y rpinst u>,
For %-1,i u-ody
permit Number —
✓/ i ��} 7—Q CJr Map» Lot "
tt�acu fLia�scc/Pcrmiucc ----LIL--fie` -- �
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
...c-ia'a ,- A, ��q'G,
� 'f` Not Applicable .❑
tfeattserefomfmpraemenontracfo PP
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCEAFI=1DAi\/Il, (K.GL.c.152,,E-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...... C3
bb .
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,State and Local Zoning Laws and State of M achusetts General Laws Annotated.
V/1omeowner Signature L! 4z"M
SECTION 5-DESCRIPTION OF PROPOSED WORK(check allaaolicable)
New House ❑ Addition Replacement Windows Alteration(s) ❑ Roofing [�
Or Doors D
Accessory Bldg, ❑ Demolition ❑ New Signs (01 Decks (p Siding(E3] Other(oj
Brief Description_of Proposed
Work: j}
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
rsa�>�e tc as a iii acl dH r€>l t�xe>�� a .a MURIA
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
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
SECTION`7a.;->.OWNERAUTNORF�TIOI TO BE.'COMPLETED WHEN
OWNERS'AGENT OIk:C`ONTETAG�OR APPLIES FOIt,BUILQfRO( PERIM-tT
I. 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
I, 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
i nature of /Ag
Ow ent 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
Side L:! R:! L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage % _�
(Lot area minus bldg&paved
parking)
f
#of Parking Spaces
Fill: j
volume&Location)'
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 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 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 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 Q NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
t2 -NA
City of Northampton �w t
Building Department
212 Main Street
Room 100
n Northampton, MA 01060
u phone 413-587-1240 Fax 413-587-1272 f,
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION°1 -SITE INFORMAT.ION.
This secttorrta be compCe>Iecl byreffice
1.1 Property Address:
V, �
OueFFay�D�stricf
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ri
SECTION 2-PROPER,TY`OWNERSHIPLAUTHORIZEDAGENT
2.1 Owner of Record:
(�-CL -
Name(Print) Current Mailing Address:
5, -3ay /
Telephone
Si ature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTIOW3f=ESTIMATEDuCONSTRUCTION COSTS:
Item Estimated Cost(Dollars)to be Official Use Only
,�--
completed by ermit applicant
1. Building laij�Building.Permit Fee
2. Electrical <(b)Estimated TotalCost'of
Construction from. 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) / Q O Check Number Z703 9 oZ�
This.Section For Official Use Only
Building Permit:Number. Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2007-0492 ,
APPLICANT/CONTACT PERSON WORDEN GARY C&SANDRA A
ADDRESS/PHONE 91 CHESTNUT ST FLORENCE (413)584-3241 Q
PROPERTY LOCATION 91 CHESTNUT ST
MAP 17C PARCEL 071 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinjz Permit Filled out
Fee Paid
T_ypeof Construction: ERECT 8 X 10 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 FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
pproved 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.
91 CHESTNUT ST BP-2007-0492
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-071 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-2007-0492
Project# JS-2007-000715
Est. Cost: $1800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10541.52 Owner: WORDEN GARY C&SANDRA A
Zoning URB Applicant: WORDEN GARY C & SANDRA A
AT. 91 CHESTNUT ST
Applicant Address: Phone: Insurance:
91 CHESTNUT ST (413) 584-32410
FLORENCEMA01062 ISSUED ON.111312006 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 8 X 10 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 signature:
FeeType: Date Paid: Amount:
Building 11/3/2006 0:00:00 $25.004032
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
91 CHESTNUT ST BP-2007-0492
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-071 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-2007-0492
Project# JS-2007-000715
Est. Cost: $1800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10541.52 Owner: WORDEN GARY C&SANDRA A
Zonine: URB Applicant: WORDEN GARY C & SANDRA A
4T. 91 '^L,4FCTr\!l!T ST
Applicant Address: Phone: Insurance:
91 CHESTNUT ST (413) 584-3241 O
FLORENCEMA01062 ISSUED ON:111312006 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 8 X 10 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: Ninai: 5-A,y� OK 0(j),ZV0 7 l ,.t S
THIS PERMIT MAY BE REVOKED BY THE CITX OF NORTHAMPTON UPON VIOL/A' N OF
ANY OF ITS RULES AND REGU ONS.
Certificate of Occu anc Signature:
FeeType: Date Paid: Amount:
Building 11/3/2006 0:00:00 $25.004032
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo