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V 5"1 « DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR
212 Main Street @ Municipal Building
'
Northampton, MA 01060
a
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction sup : • -,or. The stave defines "Homeowner" as, " Ierson(s)
who owns a parcel on which he/she resides or intends to be, a one or trvo family
dfvelling, 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/footinp-s (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
understand the above.
(Home wn /resi nt'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
� 6 ��i1E AC11(tECIIE _,�
P,
DEPART}.PENT OF EtUILDP�G INSPECTIONS
212 Main Street ' MunKIA ,,Irr3��VAInf,
Northampton, AWT OIM10 A
WORKER'S COMPENSATION INSURANCE AFFI-DAWl'
1, -
(�ICCnS;
Nvith a principal place, of businesslresidence <,t:
do hemby uoai , Hide, the O!ili1S and OC naltlCS of pP.flllly i.....
I aiii 2n etnployei providing the following =Ws compansflIun coveiQ.!e for my
employees woil. Ilv oil this job:
- - --- -----------------------
(Incu -anc;. (Polio;Number) - (E�:pir.:i on Date)
( j I art a sole proprietor, ;general contractor or ha eonmer (circle onu) mi(d have hired
the contractors listed bdov who have the fo[Ic,-.;_] woCe,ejS COi??i) rS<_:io i)Cl]C:eS:
—(Nnnle of convamor) Osman= Coinp.:::r,'PM&y N nnrW (1=Mr:nv;We)-
(Nmnc of t -JP. aczor)l (j,LSUrancc CoII.:;m.y/Pt k! ,,
(Name of Contractor) (Insurance Com,;: �yii ol.ey Ntur.l.�r) z,. bate)
(Name of Contractor) (Insurance Coui,at;y/Policy Numt'ir) 1 :ri uo:;Date)
i ) �>1n a sole t;rc�p:ie:cir ziid have no one .�,�;!hil� for
( , l ?ill a Moline o%v'),C: !)CTf inning all Lie �'IOrr; iil`rsClt_
JO I fi:plc-sc l�n rare ths: .ti}:ilc f,un o ti;r_n rti;�c:play i=: to ;i-,-,-_cane, ci:.ct:a:,Yt r::::,;a r• ";j,:-- i«c:!i:: cc(
not urccc then tluro t:ui±t is wi�:c.'t•fix hrti�u;-rr rnt%w cc oa t:u�_�.:�,^_�:���trtc;�'Lic:do r.:c:n<f;crr�l!;o��.;:dr:::':�h
cmploycl urx:cr th two ci m.:�.--_uticn Ad(GL152,_-31(5)), '~n,7c 1-'
UPI A.Wx of to Myhyo(-uncle ti:o Conr;xrnation Act_.
I undmnmd On x copy of th:j c1atc--i may bo fcnx nniod to L!]Depart.-,—I of Irxuutn al Aa�1 mti Ofli—of I:--o for tltc
covaagc Vail calioo and that failure to s—Luc covcrtE�c under:cdicn 25A of MG1,152 cw lc:.d to tix PMARS
C&MAIina of a t r_Cup to S 1 50TC. o a:�'or of up to con)w nni civil ynA iu in Q Awm a-Stc;t W"k COW awl a
firm o(SI�.X)E�}'ignlm.t ar_
Fir da; n"
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02 'crrnit Numtxa _-_-- -
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Jtm ttur of f.ic n� JI'crnt arc
SECTION.&-FCO,NSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
r
Address Expiration Date
Signature Telephone
, .. ,._ 'a Not Applicable ❑
9 Reds er" e rfom m—Me—F ent�.Contractor: . . .r .. 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...... ❑
IN 0: ®4W 11� :emiarr
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 Massachusetts General Laws Annotated.
xHomeowner Signature
l
SECTION 5 DESCRIPTIONtOF PROPOSEI)WORK(check all applicable)
..,
�..,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolitio New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: l� — l��
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a IfNewhouse a"ndoradiition4_fo_.existmgaiousin ,,comp1ete"the4 6 11 owin :
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. 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____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 OWNER AUTHORIZATION'-TO BE COMPLETED WHEN
OwNERS'AGENT OR CONTRACTOR,APPLIES FOR BUILDING 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
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
N � ` GY rnct ;� A �
Signature of Owner/Agent Date <j — U3
. . .
~ ~
^ 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 be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
ffi Sp
#of Parkin �6s
(volume&Location)
" A. Has Special Pernoit/Vahnncn/Finding ever been issued for/on the site?
NO DON'T KN0W 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 Pa8e and/or Docurnent #
B. Ones the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobo obtained Obtained . Date Issued:
C. On any signs exist on the property? YES NO
IF YES, describe sizn, typo and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No ____
|FfES, dau6ribeoizo. type and location:
City of Northampton S tits der
Building Department Ct r a
MAY 2 1 212 Main Street Se er Se I
Room 100 a �r 1Ne V
4_
Northampton, MA 01060
ph6ne 413 587 140 Fax 413-587-1272 P�1o�fte, an
Otier�Spect
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION-1 -SITE INFORMATION
Thissection tobe completed by office
1.1 Property Address: g
p( d /�Q Ma Lot a� � Urnt
151 Q Ca
Ad Zone, Overla District
Elm St. District CB°District'
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Narne(Print) Current Mailing Address:
_ t Telephone
Signatux � `7 ---
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building r (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
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
Building Permit Number: d Date issued:
wv
Signature: _
Building Commissioner/Inspector of Buildings Date
File#BP-2003-1053
APPLICANT/CONTACT PERSON MEEHAN JAMES A&HARRIET H&
ADDRESS/PHONE 192 BRIDGE RD �lL` —�5--d
PROPERTY LOCATION 192 BRIDGE RD
MAP 17A PARCEL 042 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid c �
T_ypeof Construction: DEMO 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
INFO.WKATION 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 Commis
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.
h BP-2003-1053
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-1053
Project# JS-2003-1676
Est. Cost: $0.00
Fee: $10.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 14984.64 Owner: MEEHAN JAMES A&HARRIET H&
Zoning.URA Applicant: MEEHAN JAMES A & HARRIET H &
AT: 192 BRIDGE RD
Applicant Address: Phone: Insurance:
192 BRIDGE RD (413) 584-5250 0
FLORENCEMA01062 ISSUED ON:5129103 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMO 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• Receipt No: Date Paid: Check No: Amount:
Building 5/29/03 0:00:00 5019 $10.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo