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DEPARTMENT OF BUILDINIG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '
Nordiampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as his/her construction super .•,"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_WW y -
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 Wil ing departirient for tlle-City of Northampton wants-any person(s)-who-seek-tv
use the home owner exemption, to act as their own constriction 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 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
n/m understand the above.
(Home own /resi ent's signature requesting exemption)
I will call to sc edule 11 required building inspections necessary for the building permit
-- -- issued-to one.
Date
Address of work
location
/Y �� '
4�1tnN P� 7..
c3%itch nc rtta*
w DEPARTMENT OP DUILDr)�,,C INSPPCT1011•S
I 212 Main Strcct • Nfunicipal Duddin9
Northampton, DTass. 01060
«'ORICCR'S CONOENSA`STO.N MSUR1ANCE AFITM1i q-1-
I
(li ccvs xJpc-r>ry tics) -- -
xlLb a principal place of businessfresidence at: -
(phone:')
(su>wtic;tyln tr-lap)
do hereby cercifj--, under dic-pains and penalties of pefJury., -_hat
i
( ) I am an employer providing the following WorkCr'S COITIOCnSc:JOF, coverage for my
emplOviceS vvorlong an uus job:
i (instu-_n= Comrzc}•) (Polio: ?vL r) - (r:vir�dor.Day.)
i
( ) I am a sole proprietor, general contractor or homeowner (c cie one) and Dave hired
the concractors listed below wbo hive the follow' g workers comnen_ta 'on pokles:
i
i
(Nam Of Coo'.=—,or) (Iri-surancz Cornowly/hGUC, ���utlLt:) (rti01Fd0^?(711C)
I _ -
(NzMC of Contractor) (Irssrane ComoaaylPoties Nt�crt) (La�+rlion Dale)
I
(Name of Coazacto;) (i�uance Com
- pa.n}-1Pobq• Nasls:.r) (E-vniroen Qatc)
I -
(Nz-Me of Contractor) (L=uranc_- Company/Policy Numb,`r) (Expirdoa Date)
(ar..aC�:d:ti�ooJ�c�.if a�•�-.,.•ti.�a,c?u�iafocn,�oc pc,aiains w.11 oo�_cv:s)
i
O I am a sole proprietor and have no One working for me.
( I am..a home owner performing all the work myself
NOTE:pl=se be atvzrt u _jij,bcm�vvcn wto a>7ploy pes on cr.uaa c rrr aa oc o c f
oot mots tb:.a t_4rr_uxaiix is%rbch the bomoo we rgid=oc oa the Qvun.6 zppQrtc==tbeen�z ox Ca=-ay oecd�-td to be
eitployez urx e the..�i M ,,r, :aica Act(G 0152.=t(5)��;*U=6oa by a boa=m r fc_!ice_or pc-mir r=y c,idco=Lb-C
Ic6st c zau of ea-:Ploy-uadcr dw Workor'.Coospam..tioa Act-
•' [uad=--d the a Dopy of this mtemr a may be for-__s t d to the Degertmara th,
oovcasc re cztioa and ttr_t L-jtac to sc=M rovci utxic 10060a 2311 of M(DL 152 m lcd to the im xismm oCrr m: .i pcailtic
eaorisi xg of a fine of up to S 1}00-00 andlor ttrz{atso or up to Doc y-_r and cci]peaaltin w 6c form of a Slop Wori Ord-sod
firms oC S 100.00 i ay�pinn ax
_-----
LVV, Permit Numb- —
I I
S,�natu.-c
SECTION 8-CONSTRUCTION SERVICES a
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
17etfereconrrng�` ee0offira�o= 0 416 Not Applicable ❑
Company Name Registration um er `"- -�-
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFF DAYkT(M G.L:c 152„x§- (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 1083.5.1.
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 shag 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 an j Loc 1 Zoning Laws and S e of sachusetts General Laws Annotated.
Homeowner Signature
r
I
SECTION 5-DESCRIPTION OF PROPOSED WORK(checkrall.aaplicable)
New House ❑ Addition ❑:; Replacement Windows Alteration(s) Roofing
yam{ Or Doors 0
Accessory Bldg. lLJ Demolition ❑ New Signs [0] Decks [C] Siding[O] Other[❑]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative e , Renovating unfinished basement Yes No
Plans Attached Roll -Sheet J �C' 'X/
sa.( fie �ioasa r �Qr �i lrexi� cio-csinct-carrtpCe�+ h . Four lng:
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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT�OR'C6NT.RA'GTOR'APPLIES'FQR`600114 n: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
I, C11i8LL FAZ4�/� � Lrri , �/ /�/'/ 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.
eX t-L ENS R L` alT .A/ --
Print Name
1
Signature of Owner/Agent of Date
Section 4. ZONING All Informatioh Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
NO Building Department
IF
Lot Size y
ii
Frontage
Setbacks Front I r
Side L:� R:4-5' L:E:� R:' I
---f
i
Rear i
Building Height 7 7=='
f
Bldg.Square Footage ' %
Open Space Footage / %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill: III
(volume'&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
Mh
NO DONT KNOW 0 YES 0
IF YES, date issued:; i
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES
IF YES: enter Book Pagei 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 Q Obtained Date Issued:
C. Do any signs exist on the property? YES Q 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:
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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
(,.'City of Nort ampton
uilding Department
212 Main Street e
Room 100 . ,
Northampton; MA 01060 sa
phony X1,13-5$7-1240 Fax 413-587-1272 y Cara
iJ Oth peer «
APPLICATION— CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION A,-SITE INFORMATION
1.1 Property Address: ����» This section to=be completed by office
c Ile t, /—r cs'j a dot UnMt
F,1 C)�'j eC /J overrai3�Encf
"SECTION 2-PROPERTY OWNERSHIPIAUTHORIZE 7 AGENT
2.1 Owner of Record:
Name(Print) /� " l c///''+�r' Current Mailing Ad ress: ,' J
it
Telephone
Signature
2.2 Authorized Agent:
c Key �>i �`T r?' ei 7`l�i�/►� /�'
Name(Print Current Mailing Address:
Wzk�7_� 4031 -2
Signature Telephone
SECTION 3-ESTIMATED,-CONST.RUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction.from 6.
3. Plumbing Building,Permit Fee
4. Mechanical(HVAC)
5.Fire Protection ��M✓�r'
6. Total=(1 +2+3+4+5) (l E , ✓ Check Number
This`SectiotrFor Official Use Only
Date
Building Permit Number. I lssuedc
Signature: '
Building Commissionerlinspector of Buildings- Date
File#BP-2006-1279
APPLICANT/CONTACT PERSON WHITHAM CHALLENGER J&HELEN P
ADDRESS/PHONE 112 CHESTNUT ST FLORENCE O 586-2531 Q
PROPERTY LOCATION 112 CHESTNUT ST
MAP 17C PARCEL 089 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin 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
TH OLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IPRMATION 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 Stre7:Cosion
Signature of Building Official Date AJ
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-2006-1279
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2006-1279
Project# JS-2006-1884
Est.Cost: $1000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10628.64 Owner: WHITHAM CHALLENGER J&HELEN P
Zoning.URB Applicant: WHITHAM CHALLENGER J & HELEN P
AT. 112 CHESTNUT ST
Applicant Address: Phone: Insurance:
112 CHESTNUT ST ( ) 586-2531 O
FLORENCEMA01062 ISSUED ON:512512006 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 5/25/2006 0:00:00 $25.00263
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo