17A-149 (5) $: � �ASSAClt lSlittl8 �
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street 0 Municipal Building
Northwnpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/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 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 11 _
I, > T'`�l� Ma. understand the above.
(Home owner/resident's signature requestini exemption)
•i i i i ti t---[t-J•-- •-----a•...... .....,.,...•.... 4:'--+1,- 1.,,;tit;— �orm;t
1 will call to schedule all,l equll et1 -ulluill6 iva�rrt LiVu3 i.c�wOau y .v. Lilt ..u.......b�..• -.
issued to me.
Date 3131 t 941
Address of work ,� Q ^, r V Ak S 'k0 a-
p
location �u 1�- 1'� K
(� MA- 0 14Co2
ye (rii-� of Parfliai)tp toll
A � f ��asanrEJt:srlts' __� _
DEPARTMENFF OP BUILDRNC INSPPCTIOt.'s — —'
212 Main Strect - Municipal Building,
Northampton, Mass. 01060
tiV O MCE R'S CO iKP EN S A`n O N, M S URAN CE AF TF, A�TI.1- '
(li�nsaJperm tom) ,
r1i }� f�l a �f-l��sin�sslr�s i d�t� t
ag F�{ S (ZDlt 1 ,lionc
do hereby certify, under die-pains aild penalties of pe>7ury, ._hac `
( ) I am an employer providing the followine %�,orkcr's comocnsZdo cove mac for im
etupiovecs vvorUng on this job:
(Ia ur-�c Conrw) (Polio:N"L-ter) --- (T :-piraior, Dzt:)
O I am a sole proprietor, general coonaaor or homeowner (ci cie one) and have hired
the cones actors Listed below who hive the following Worker's comnen-Sanon pciicies
+IlIllC 0i Contmaor) (InStlranc^. CoinpaJ'yili obc-,-,tU41.C:) (Y?:73id(3Q D8[C)
(Name of Coocramor) -- (Insurznc Comoan-vvPolic' Ntlsncrr) »ir[ion Date)
(Name of Conn-acor) GMI.Lrancc Compare}'/Pogo}' Numbs) (Eapir:aea Date)
I
(Name of Contrectar) (Insutan ComcaaylPogcy Numbs) - (Expu-adoa Date).
(acid:dii�oc�J bcC it ncccai�w a�c'u�iarorm,600 pcsta:ain6 to.0 occ=--=.�) -
O I am a sole proprietor and have no one worid.ng forme. '
( I am.a home owner perfonuing all the work myself.
NOTE:plesc be ew r,ti— jzilc Ixmco vcrs�+.bo cmpiay pesaos w U r,n
=s.;caoo c tru, u wori:on a d�c1Lg of
ant mete the .>=.ts to\aiyc6 the bomoowoe ressc'yo a oo the Qaetnra zpputt.cnn tbeeo LT ooeeaRy 0.-c:,d–�Lo be
cnploycs and;tbc..ni��O=P' --+;C,Act GL1512y 1(S
( )}.n.pplintAOa by n homcowyC fQ c(icy_or pcnnit n_y ctiidar_c the
Icgi1 ctaIIU
or--0 c=Ployet-odor thn Worilo ,Coc�oa Act.
undcszaad the a Dopy of this aat®ria may bo forxarded W tha DcQa.,timcat of Indaau;ci AccCcot�'Dlrioo of ltn+ranoe for tho -
covera.se�iretioa a.nd{}�L-iltse to uauc`eovety�tmc',ct soetion 2SA of t.tOL 152 m Ied to the i ,�ition oCeimiuil peasltic
comirmg oC a rsnc of up to S 1 y00.00 and/or orup to ooc year end 6Nil pco..P,ia in LSe form of-Stop Wor'[Ocda and a
fim of 5100.00 a day api=ED,-
- _ -- -- For
Pmi, L u.c only
crmit NumUt's
(P Ada p::_ Lot K
Signaturc of Lic=Lsc&permi —CF3Le )
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9.Reaistered Home Improvement Contractors Not Applicable ❑
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...... ❑
11. - Home Owner Exemption
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.
Homeowner Signature �✓1/l
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 [0] Decks [M Siding[O] Other[a
Brief Description of Proposed
Work: '1
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes U000 No
Attached Narrative Renovating unfinished basement Yes ✓•No
Plans Attached Roll -Sheet
6a. If New house and or addition to existing housing, complete the following:
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-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS�AGENT OR'CONTRACTOR
APPLIES FOR BUILDING PERMIT
"— 1 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, W�a< ' ° `� ��� 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 aqd pqC Ities of pek
..Print Name
-3/31/0
c�
Signature of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
No �� This column to be filled in by
Building Department
Lot Size r. L V .,_ -l_•y��5� ..,
Frontage V
Setbacks Front r�
Side L: r 7 R:t ! L:'
Rear - --
Building Height
Bldg. Square Footage t''l %
Open Space Footage(Lot area minus bldg&paved
parking)
#of Parking Spaces 115(o
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW kP7 YES 0
IF YES, date issue&
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 NO
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
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.
r
Department u66 only.
i� o Cthampton Status,ofPermk,.
C partment Curb GufilDrrweway Permit
=v' 212: a Street Sewer/Septic Availability
i •pi °`4F
100 Water/WellAvailabillty
1i I Northa ton,'MA 01060 Two Ws of Structural Flans
phor1p4.13-- 240 fax 413-587-1272 Plotsite Plans
DE T or .. r,iClo IPISi t 06 NS i Other Specify
rCl, L-ITAW U1 APPLICATION TO CONSTRUCT,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
-D46 rv ��� Map Lot Unit
MA Zone Overlay District
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
70(l y d oc t-C.t�y� ion Ma (Xa h 5�n SGT —
Name(Pri(�,, Current Mailing Address:
Telephone 3 l
Signature
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 (a) Building Permit Fee
2. Electrical (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) D
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building ermit Number: Date
g Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2006-1022
APPLICANT/CONTACT PERSON MAHONEY PATRICK J&CYNTHIA M
ADDRESS/PHONE 28 FOX FARMS RD FLORENCE (413)584-8944 Q
PROPERTY LOCATION 28 FOX FARMS RD
MAP 17A PARCEL 149 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Perniit Filled out
Fee Paid
T_ypeof Construction: RENOVATE BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessoly 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 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 Elm Street Commission
ignature of Building Official
nature
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.
2 `FARMS RD. BP-2006-1022
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-1022
Project# JS-2006-1523
Est. Cost: $6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: Homeowner as Contractor
Lot Size(sq. ft.): 14810.40 Owner: MAHONEY PATRICK J&CYNTHIA M
Zoning: URA Applicant: MAHONEY PATRICK J & CYNTHIA M
AT: 28 FOX FARMS RD
Applicant Address: Phone: Insurance:
28 FOX FARMS RD (413)584-8944 (�
FLORENCEMA01062 ISSUED ON.4/7/2006 0:00:00
TO PERFORM THE FOLLOWING WORK:RENOVATE BATHROOM
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 4/7/2006 0:00:00 $50.002550
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo