17A-110 (4) 4'St1AMP�.
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DEPARTMENT OF BUILDING INSPECTIONS
r
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 l;is/her construction supc:.,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
understand the above.
(Home owner/reside 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
R `E ) Of aIII toll
DEPARTMENT OP BUILDr,\1C INSPPCTIOI.'S - —
212 Main Strcct ATunicipal Build'
ing
Northampton, Mass. 010GO
j
i .
«'OMCEIt'S CO CPENSATION 134SURACE AF FMAVIT
' (Ii txnsxJpc�-tni tt x)
with a prb"Icipal place of business/residence at:
P —
(SLrc f/Qty/R21r-fZJn)
do hereby certify, under the pains and penalties of perjury; :hat
( ) I am an employer providing the followinL worker's colnacnsadop cove mge for illy
emplovecs working on this job:
j
Comp„m•) (Policy ?;u-mb-cr) (r:pirtior, Dzzr}
I am a sole proprietor, general contracior o homeowner c;e of?e) and have hired
the coniractors listed below wbo have the follo�vi�� -er's ra�oensanon paKies:
([+1lnc Oi Co-t!a0r) (InRranc: Coinp3,i)'/1 oU(7i ? UjM1--C:) bate)
(Name of ConQaaor) (lnswznc Comoaa`vPo!ier \umi:sr) (Lx-Dir,Lion Date)
(Name of Connaetor) (Imsuraecc Compan)•/PoUg- Nambzr) (Expi z6oa Date)
(Name of Contractor) (Insumacc Compacy/Potiey Numbci) (Expiration Da1c)-
(atxacb t:�oc�1 cbcd,ifnccr�al-tp mcaud aform,aoa pertainins to.t!
{ ) I am a sole proprietor and have no one workiDg for me.
( ) I am.a home owner performing all the work myself.
NOTE:p(=..sc be ew-A=ts—1+-f=-Ic hcmcovvcrs u-bo¢aptaY P,zoru w c1�c• -e,ao r repair..-ork on a d..cll_g of
Go(mat the 11,1-+0-_Larj in«'.ric:h the bomoo—un r=id=or on the p-ouaF_,z�puttcn•�tl=-cto r.-z o-x C=):-Uy oc-=d`-cd to be
caployc�uac c the k—i:a',—*=r ca Aa(GL152=t(5)�n.pptiarioa by a homco%-=for_lie==a pcmh r=y c-,dao=trc
1c-®1 n,�.,-r-x==Ployar=&d cl�W«f.�ea Coo . o Ad
1—dcszaad tba:Dopy of thu=xL=ma ma.y b.forwarded a the Dvp„z—=r of l-6—id Aoada&Off oo of In i,r.00e foe LS.
oovcf"& c vc Sc=L'oc nad th=t L-dL7-to L==)Covmise und=s=ion 25A of?,(GL 151 nn lad to the iavm6oa of aimi-1 pcaiiG,=
oo===zg of a rmc or 1W to s i Soo.00 ands., of up to ooc ya e od a vit pc rja in tx form of a Stop Work Order and a
run of S 100.00 a d_y apu¢A mc.
/ o
.rt ,,-,J use n)y
For
dcp
permit Number
Lot . ;
�Siztum of e )
I �
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: r\ Not Applicable ❑
Name of License Holder:P ` c J�` m V
License Number
Address Expiration Date
Signature Telephone
Not Applicable -❑
9.Rexistered`Ho`me trip"r6vement.Contractoi" Pp
a w) 4f P0
Cglariv Name Registration Number b - n&t vt i(Ax Z t5 TL
Address ��� ��3_, 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...... ❑
a k x,.
11. ome pwrie>r�Fgemua
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 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"certifle d assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and dZ in Laws agitate h s General Laws Annotated.
Homeowner Signature
SECTIO 5-DESCRIPTION OF PROPOSED WORK check all applicable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [0] Other[E]
Brief Description of Proposed 7
Work: �/
Alteration of existing bedroom Yes No Adding new bedroom Yes �` N
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.Ylfi�New�ii`oase and�r a'cl�ditior>��`to ez�s#ing housina�� mplefe�#fie' fofl'ouuina:
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 BE COMPLETED'WHEN
OWNERS AGENT OR CONTRACTOR.APPLIES FOR:BUILDING PERMIT
Ph111P 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.
M4,01 a—
Signature of Owner Date
as Owner/Authorized
Agent hereby declare at th4statents 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
Signature of Owner/Ag t % 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 � D �^ ,
Setbacks Front Ct
Side L: �!'s! R: L: R: H
Rear
Building Height
Bldg. Square Footage % ;
Open Space Footage
(Lot area minus bldg&paved
parking)a
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES 0
IF YES, date issued:;
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 DONT KNOW Q YES Q
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 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,a cavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Building Department
X12 Main Street
Room 100
Nb mpton, MA 01060
phone 413-587-1240 Fax 413-587-1272fo ans
— - APPLICA66N_&MbWgv ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -`SIT.E INFORMATION
1.1 Property Address: Tfiis secti to be completed by office
Map Lot Unit
Oaer 4a'. istr�ct
Im St District ` w": CH,D�slrict
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
G � �( ' \ �I�..
f' Telephone
Signature
2.2 Authorized Accent:
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)
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
I J
File#BP-2006-1098
APPLICANT/CONTACT PERSON COSTELLO PHILIP A&MARY R
ADDRESSIPHONE FLORENCE
PROPERTY LOCATION 21 CLAIRE AVE
MAP 17A PARCEL 110 001 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
Typeof Construction: ERECT 12 X 16 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
THAFLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INATION 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 El eet Commission
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.
"j
;4 'iv, ATT S
GIS#: 4
OF .'ON
Ma Block: 17A- 1 0
Lot: -001
Permit: Building
Category: BUILDING PERMIT.
Permit# BP-2006-1098
Project# JS-2006-1620
Est. Cost: $4634.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 9016.92 Owner: COSTELLO PHILIP A&MARY R
Zbonipg-URA Applicant. COSTELLO PHILIP A & MARY R
AT. '21 Qn r7-,.-
Applicant Address: Phone: Insurance:
FLORENCEMA01062 ISSUED ON.412512006 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 12 X 16 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:
Mn-ts; Emek_ . Final; K 7- ;?S--o4
THIS PERMIT MAY BE REVOKED BY T CITY OF NORTHAMPTON UPON VIOLA99N OF
ANY OF ITS RULES AND REGULATIQO§.
Certificate of Occuvanc Signature:
FeeType• Date Paid: Amount:
Building 4/25/2006 0:00:00 $50.0096526
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo