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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 2'12 Main Street • Municipal Building '>o
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 supc:.•i:>or. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,a one or tvo
anu 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 6uildin—g department for the City of Northampton w_ants--anyperson-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 fegulations. 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 owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued-to me
Dates
Address of work
location
1 �
0 E (rii� of PTCriIialllpfoi_l I_
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g�c�anc}Inirlle
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w d DEPARTMEITT OP BUILDr lNSPPCTIOI.'S
212 Main Street 1tlunicipnl Building
i Northampton, Mass. 01060
I
- .._ ... `SrfOi1J-L...R's CONITENSATIO.N MSUR CE A L l-11JC .V 11`
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\=11Ith a principal place of busiaessfresidence zt: -- - -
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7i OCR (:M" 12(/) (Nl(.(�I � (phone') AiIi (A6 ?,91'7
(SO-CwCi rr/sta.tda P)
do hereby certify, under thc.pains and pen2lties of perjury,
( ) I an as employer providing the followine ork-cr's coinocns-Don cove ale for 111)
etvplovees wor>dng on tills job:
i(
(I-_nu---nc Con ate) (Polio: Nu--ter) (=:pir`nor. D2i--)
( ) I am a sole promieror, general contractor or hocieov"mer (Cl c,e OP-e) a-od have hired
the cona•actprs used below v-rho Have the folow-mg, worker's comptn_t2ilion pokies:
� It+^Il]e Oi CO"_^CiO�) (InRli3nC.^-COIDD151}"fl�GUCi ��rL1.n1:C:) iL-'.Jlr'J::4?I�aIC) -
I - -
(Name of Conrracior) (1rLSarane;. Company/706c, Nu b-c-T) (-E%Dimon Dae)
(Name of Connaao,) (Franc:Compan}-/Folic}" N:tsbz.r) (-ENPirz6on Daic)
(Name of Contractor) Gnsuran=Comcany/PoUcy Numb:r) t���tr�on DaLr).
(nr.-G'L roc .l SSCG',if acCC1'w aic?ts�-tafalm oa pctnia:ac to all
(%/I am_a sole proprietor and have no cot worFg for me.
{ ) I am,a home owner perforFng all the work myself
NOTE:pi—be tYt)a Q=PIOy➢C'LQp1 Lo CU C' Ct^• c-,=,oa c rgas work av a d,,cll of
act taco:t� t'�o >ar�in%�ixcfi the bamoo we rcmda oc oa the V-ou� z,�typo L:ox C=.lZy oed.-ai to tic
is - �-the�.
`� y"z ���— ,:cn A=(GLl52.n 1(5)).=ppG=6on by>hamcoQaa fC pcZni::`-y cti-id=x t1v
Icgsl rt_^„of en c-jioyx uoder djo Wortida C.ocrr nvtioa",L
I L:adcTS aad the a copy of this cntcmea may yo forty. i,d Lo the Dcgnmm¢orj d�r i (Ae Ad y Omoe of lrr� !or L5.
ooYC�-e"'e veiCcioo:.ad tku L-ilLac tv s�uz tov�o uadc socxion 23A of}.LQL 152 ea Ie.d to the iioa of eimiad pcualxio
ooau:x�of a fine of up to s 1 Soo.00:ndfor ieap;iseamat or up to ooc y-._.•.ad c%_U pco.I-i=is d,form or a Slop Wort Ord:. Lad a
ri=of S 1 oo.DQ.d_y.pi=CD--
For d,,_ -•'uic only
PCTlnit NUML--T _
Lot rt
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SECTION 8-CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor. Not Applicable /�❑
Name of License Holder: adA'6-G 6O li 1 1 le I
License Number
OLj l(i(i Sl3 tlrlPi '4 • t 1 • D>b
Addres Expiration Date
Signature Telephone
9�'�2ea�sfere�ome�mprovbrnen�optraptcir.� r��. ` �; .' --- Not Applicable ❑
1l
Orb
Company Name
Registration Number - -- —
I_ I
Address Expiration ate
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT 0 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...... ❑
11�� IDltri O_ e MN"
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-vear 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 buildine 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
r
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SECTION 5-DESCRIPTION OF PROPOSED WORK{check all applicable)
New House ❑ Addition ❑:; Replacement Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [M] Decks [M Siding[p] Other[C7]
Brief Description of Pro po ed
Work: AIAVIJ 6-X15 f71V 4 ignEgn& 4
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
x....� �° "£'�'"5 .•n;•�.•+��=.;cY+x �L`a4++s. H.- ;—.,,efr"'--�,;- �. .^'.�"s" �."._:;: �*r?+.ga �,.- -^ti s, -.
6a-(��NeW�'o�se�nd-~�rTadditio�to.�extstii�ct,tiousingvcompfiefethe�fotCQw>Ing:
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-OWNERAUTHORIZATION-TO,BIE,COMPLETED WHEN
OWNERS AGENT,OR CONTRACTOR'APPLIESPOR'BUILDINGPERMIT
as Owner of the subject
property
hereby authorize L1 wl 6-&
to ct on my behalf,in all matters relative to work authorized by this bui ding permit application.
(� (:�(� (oS
Signature of Owner Date
I, gL 1 CA OL I J�J�'�I S e 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.
T Si ned under the pains and penalties of perjury.
i
P'nt Name
Signature of Owner/Agent U Date
Section 4. ZONING All Informati6h 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 —OLY Z
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bIdg&paved
#of Parking Spaces
(volume,&Location)
A Has | Perm�/Varunca/F ever been hsuudh�/onthe sha?
N"
0 0DN7KNOVV m7,% YES 0 �
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO K J DON7KNDVV YES
^�
IF YES: enter Book Page, and/or Dooummnt# '
�� ��
B. Does the site contain o brook, body of water orwetlands? NO ����L DON'T VV �~�KNOW YES �_�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
'
Needs tobeobtained v~~� Db�o�nad v�� 0mt� |saue��'
�~/ \~�' '
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C. Do any signs exist on the proper�? 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 y—� NO g
IF YES, describe size, type and location:
E. Will the construction activity disturb grading,excavation,nr filling)over 1 acre orisd part ofo common plan
��wW|dio��me,1onn? YES NO W
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
������
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1
�°" Depart�ett.usonl� :°
---""` ity of Nortt am.pton
µ_
��n6wlding Department Y
�12 Main Street e ,
Room 100 a^ w
o ZQ�S �,i..e p ton MA 01060
am ; a S ans
phone 413-5 7-1240 Fax 413-587-1272
=�LICATIQ T. -"a 6RVRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 --SITE INFORMATION
1.1 Property Address: This section to be completed by office
f"v�YjiF%�'!�G(� �'��e 4verlaly°Dlstrtct
�K
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
&/Nq N SA ivy
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Accent:
to4K I e.i(>. CyJ ef-5 cee+ e tk-e e_ hl�c
Name(Print) Current Mailing Address:
`E 13 11;'E)(0.-:10
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building Sl!g j v 0 (a)Building Permit Fee
7
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing / 76a o Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) aV Check'Number
This'Section For Official Use Only
Building Permit Number. Dsued:
Signature:
i
Building Commissioner/Inspector of Buildings Date
File#BP-2006-0371
APPLICANT/CONTACT PERSON DANIEL HATHAWAY
ADDRESS/PHONE 2 OLD GOSHEN RD WILLIAMSBURG (413)268-3135
PROPERTY LOCATION 24 SHEFFIELD LANE
MAP 17C PARCEL 119 001 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 42YO
Typeof Construction: NEW BATHROOM FIXTURES/FLOORS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 081793
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Ehn Street Commi n
�D
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.
4-
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BP-2006-0371
24 SHEFFIELD LANE
24S#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 119 CITY OF NORTHAMPTON
Lot: -001
Permit• BUIICIII1Cl
: BUILDING PERMIT
Category:
Permit# BP-2006-0371
Proiect# JS-2006-0540
Est. $Cost: $11549.00
Fee: $ost: PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DANIEL HATHAWAY 081793
Lot Size(sq. ft.): 20778.12 Owner: DROOKER HAROLD&NINA
Zoning:i1RB Applicant: DANIEL HATHAWAY
...-
24.Q r-F is l E l 1D
Applicant Address: Phone: Insurance:
2 OLD GOSHEN RD (413) 268-3135
WILLIAMSBURGMA01096 ISSUED ON.101712005 0:00:00
TO PERFORM THE FOLLOWING WORK.-NEW BATHROOM FIXTURES/FLOORS
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Lispector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
nn/ J Footings:
Rough: - -'V b" ought(r t � t.,Mouse# Foundation:
(�Z1� � Driveway Final:
�J `2111.14,4 U�
Final: .-�j ��I��W Final•
Rough Frame:4
yy
Gas: Fire Department Fireplace/Chimney: Ll
Rough:
Oil: Insulation:
Final: Smoke: Final: e�
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL ION
Certificate of Occupancy C1C 4 Signature:
FeeType: Date_Paid: Amount:
Building 10/7/2005 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Conunissioner-Anthony Patillo