17A-158 (3) LIVING AREA
160 sq ft
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DEPARTMENT OF BUILDING INSPECTIONS
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 his/her construction supci., sor. 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/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 1p
Address of work
location ��.` �d 2
(fl; of
UEPfiRTMENT 01" BUILDP�G INSPLC71ONS
212 Matti Street Municipal Building
Northampton, if ass, 010GO
WORICER'S COMTENSATTON INSURANCE AFFMAXIT
o" "h 2, principal place of busiraess/residence t.
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I am an empioyer P-rovidin- the r'ollovl7i ""L Uun 0-, Tily
eluptovcts working on this job:
(In =c-z Corset') e::"Number) Date)
A I =-i a sole proprietor, _,tn-rL1 c-.�ntmc-,cF Oct) and gave hires
th'_ Colltractm liste'C beiov." ;"ho
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(Na-me of Nw-ntcr) -xp Di,tc)
(Namt of Dale)
(Name of Coat-mclor) Tnc-, Dalc)
(Name of Cont Actor) JDE,1=1(�` CC,1117
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SECTION 8=CONSTRUCTf;ON SERVICES
J.
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
�.gte 'om�e ° _ 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...... ❑
I',. Me.
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 acecptable 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.
_LJHomeowner Signatures' I� zoy Y/'
SECTIONSDl`SCR PT10N0F PROPOSED WORK[check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s)54 Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: Tj
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll D • Sheet D
65-13 CfiNew housatidor�'dclit�onutoex"ist>n�;1o`usingLcomTete the fol.lowrng
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. bimensions
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
SECTl01�17a �YSINERAUTH0RIZATION ="TO BE COMP,.,LETED; WHEN
OWNEEtS'gENTOR CONTRACTOR APPLIES FOR BUiLDING.PERMiT
A6 G— el"., 1 fge:l as Owner of the subject property
hereby authorize to acs or,
my behalf, in ail, matt s relative to work authorized by this buui ding permit application.
Signature of Owner Date
1, 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
Signature of Owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
Ibis column to be filled in by
Building Department
I
Lot Size
I
Fronta e
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
P P g
(Lot area minus bldg&paved
parking)
I
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO V DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW
YES
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_
No
IF YES, describe size, type and location:
s
City of Northamptonvti
Building Department
212 Main Street ��
Room 100
Northampton, MA 01060 Lwo
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DE O E _'gFAMILY DWELLING
12004
SECTION 1-SITE INFORMATION APR 2 7 "
TA+is sectwn,to be comptetied lby office
1.1 Property Address: N ,A
Sa FLA U& ROAD
�,,Eim Stk,D�stnct= ` '� CB, �istriict
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED.AGENT
2.1 Owner of Record:
D00 6W hik WL FDA FAM5 QA D
Name(Print). -, 7 Current Mailing Address: `14-�
7
Telephone r^Q L
Signature ) U 6 1
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3- ESTIMATED CONSTRUGTION'COSLS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant -
1. Building j / ba (a)Building Permit Fee
2. Electrical 3(),q (b)Estimated,Total Cost of
J Construction from 6
3. Plumbing 2 / 6 0 Building Permit Fee
C) J fC'
4. Mechanical (HVA
5. Fire Protection
6. Total = (1 +2+3 +4+ 5) (� Check Number �D O
This Section For Official Use,Only
Building Permit Number: /60(2 '"/6 37 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-1037
APPLICANT/CONTACT PERSON ABEL DON&ANNE A?a&
ADDRESS/PHONE 53 FOX FARMS RD FLORENCE (413)586-1877 Q
PROPERTY LOCATION 53 FOX FARMS RD
MAP 17A PARCEL 158 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid 7520 48 6-0
Typeof Construction: REMODEL(2)BATHROOMS
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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF,PRMATION 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 Commissio
z; zao
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.
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53 FOX FARMS RD BP-2004-1037
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A- 158 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2004-1037
Project# JS-2004-1561
Est. Cost:$10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License.
Use Group: Homeowner as Contractor
Lot Si2e(c19,ft.l: 2793.16 Owner:_ AB_E_L DON&ANNE
Zoning: Applicant. ABEL DON &ANNE
AT. 53 FOX FARMS RD
Applicant Address: Phone: Insurance:
53 FOX FARMS RD (413) 586-1877 (�
FLORENCEMA01062 ISSUED ON.4/29/04 0:00.00
TO PERFORM THE FOLLOWING WORK.-REMODEL (2) BATHROOMS
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:; f, Rough: �lv lr� House# Foundation:
I / Driveway Final:
Final: � Final••l�.!��
!" Rough FramerK 5— Gi
Gas: Fire Deuartment Fireplace/Chimney:
Rough: Oil: rEa4::1��itt:2:
Final: Smoke: Final: q
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATION
Certificate of Occu an Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 4/29/04 0:00:00 250 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo