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DEPARTMENT OF BUILDING INSPECTIONS J
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 sup,,,: ,,,,or. The stave 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 buildinL 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
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 9D C"U� st
of �Rrfllanl}�tolt
A J f 61zaaachnsrtIs' _
w o DEPARTMEWT OP DUILDD\10 INSPECr1O1.'S
212 Main Strcct Municipal Duidin�
i
Northampton, Mass. 01060
a'
WOR1C4:R'S COnUENSATION MSURA3�CE A17FMAVI-I'
Oicc Jperm)tfec)
\vILh a pnncipa.J place of busioess/residencc at:
L�
(SD-=Jci ty/state,/a P)
do hereby certify, under the.pa_lrls 2nd penalties of pcg'ury; ihai
( ) I am an employer providing the followine wori:cr's comocnsazj'op cove fm
;c for my
etuployccs Nvorldng on ulis job:
J
i
' (Lmuran=CoEi=ml) (Polic: ?3u-nir_r) --- (r;pir<aor. Dpi-)
( ) I am a sole propretor, general contractor or homeowner (circle one) aDd have hired
the conuactors liste—d below who have the ;ollowv cg worker's policies:
. ([+amc 0 Con'^ci0r) (1n urancc. Cornp3,i),fPoUCi T�it12I1�G:) -- (Ekpmduon Date)
(Name of Coonclor) (Uisuran Comoanyt?olic; \ulmc-cr) (hxxir,lion Date)
-
1
(Name of CoaEmc,6 ) (Insuran= Compao)•/Pol;q- Number) (Expirdoo Date)
(Name of Coutraaor) (Insurancc Comt;auy/Policy Numbcs) 'Expim6oa Da c).
(aIISC�sddi;:oc�1 bcrl.ifacOc --V to Mrortaa.tioc pcna' to.L c+c,�-won) .
{ ) I am a sole proprietor and have no one wor�dng for me.
I am.a home owner performing all the work- myself,
NOTE:pick be aw-xt d—..1 Jc 6cc=o, n u ba cEmplaf pc coz to&_:.-.,--,.
�-:c�oo c rtpair.+•orX oa i d«clL^;of
aot more th-- term t-2ra is u+sich tlx b=--,cr rt.&.a cc the pvuads zppurte�•�tbeen c c oa aca--Xy a a:d=cd to be
citployea unr_e the..aS c{i a=*=:- c.qn(GL152-a 1(5)),appU=L6c3 by a bomcow-oe fcr:6c=—a pcmit r=y—id�ELc
jtc!tl rt.o=of as erployx under dt.o WOAS -[Cocap.amai.ioa Act
I uadesLnd t1�x oopy of tbi.mt®eoa o,y b.foe+.ardeE to the D zq. m of, id Aoo& Offi—of In th.
00v= c vcif cnioo and ttu Utae to cecurc tovery�c track%ccxion 25A of MOL 132 tan tad to the i=poikioa of eimiwJ Pco 16=
coaiiai g of a rive orup to S 1 Soo.00 aztd/or r of up to Doc year end civil pm.hio w form of a Stop Wort order aad a
rim or S100.(?0.d y e� --I me
For dc�.rtrz�=31 u.c Drily
PcTmit NuIDbC1 --
Si9p,Zwn of Lia=iscclperrniucc e )
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
,. � � > NotApplicable .13
9 R'ens€efedi�omeampro�remerif�lontracfor° ;,r; _� :: t- � ,, .. ,„� �,�,,,,, °�.� Pp
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...... ❑
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 resppnsl#lity for compliance with the State Building Code,City of
Northampton Ordinances,State an o g w n ate of Massachusetts General Laws Annotated.
Homeowner Signature 6-C12 7
SECTION 5-DESCRIPTION OF'PROPOSED:WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. y Demolition ❑ New Signs [0] Decks [M Siding[O] Other[0]
Brief Description of Proposed I
Work: &As6a
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Ye No
Plans Attached Roll -Sheet
.G '.rt'a �.r ..„,t sM',t
sa if t+dew ouse arrd orarld dtfw :avexlstin ,.Ta�us>�n com Cet the of
a. Use of building:One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathr s
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 constructio 0 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. XZ cellar floor below finished gra de
k. conform to the Building and Zoning regulations? Yes No.
I. City Sewer Private well City water Supply
SECTION 7a-OWNER'AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR'CONTRACTORAPPLIES FOR".BUILDING PERMIT
as Owner of the subject
property
hereby authorize
to act on my behalf, in a ers relative to work authorized by this building permit application.
Sig a of Owner Date
I, Ec� � CIP 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 pena ties of Ter-,k
jury.WIV1
Print Na t;wmg� 6
Signature of O er/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 �� b
Setbacks Front
Side L: R:-4- L R:i
Rear ..itz -" '��'�
Building Height t
Bldg. Square Footage % -v
i
Open Space Footage % i
(Lot area minus bldg&paved
parking)
1—IC7
#of Parking Spaces �-- t—
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW YES 0
IF YES, date issued:i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES Q
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
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES l N0
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 )w
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
-' S ity of Northampton
d
ilding Department
12 Main Street «
Room 100 a#rr
Northampton, MA 01060e
phpne V-587 1240 Fax 413-587-1272 t
n. z 4 (w,1"�..: � 3'.W°aS€ u^',• ,:* ,.'.1 31 "`"
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This secttoirr to be:completed by ufEice
1.1 Property Address: =
�1 C��e�-n�• S Malt Una
SL Distr.�rt � = C�.1]isturt -
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
-1�,j� ��� o lawny- �r R ox 60224f -lut'ny , MX
Name(Print Current Maili g Address: 0 L� 3
Telephone
Signature
2.2 Authorized AAg'entt-
d5Y�
Name(Print) Current Mailing Address:
Signature Telephone
SECTION"3 ESTIMATED CONSTRUCTIONcCOSTS=
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
on
2. Electrical (b)-Estimated Total Cost'of`
Construction from 8
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number —
This Section For Official Use Only
Date LL
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2006-1197
APPLICANT/CONTACT PERSON OLANDER EDWIN L
ADDRESS/PHONE P O BOX 60284 FLORENCE (413)695-5580 Q
PROPERTY LOCATION 97 CHESTNUT ST
MAP 17C PARCEL 070 001 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
Typeof Construction: CONSTRUCT 230 SQ FT 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 FOLLOWING 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 I-ror a?z: SSA} /7-
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: § / 'c7ax
Finding Special Permit Variance* �Tx >
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 Co 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.
BP-2006-1197
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-1197
Project# JS-2006-1767
Est. Cost: $600.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group. Homeowner as Contractor
Lot Size(sq. ft.): 18905.04 Owner: OLANDER EDWIN L
Zoning.URB Applicant: OLANDER EDWIN L
AT: 97 CHESTNUT ST
Applicant Address: Phone: Insurance:
P O BOX 60284 (413) 695-5580 ()
FLORENCEMA01062 ISSUED ON.511212006 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 230 SQ FT 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 5/12/2006 0:00:00 $25.002402
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo