17A-154 (4) O¢StiAN1P�0
Z =
�83E8Ch ILStttE -
Y
DEPARTMENT OF BUILDi)tG 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 its/her construction sup(.: , ssor. 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
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.
Date
Address of work
location
.4
0
'.Tnrfl�a111 011
g f �a�anrltncrlta' _
u~ DEPARTME14T OP DUILDrT;C INSPECTIOIJS
212 Alain Strcct Afunicipal Dudding `
Northampton, Mass. 01060
woR14:R'S COQ 'ENSA n0N I,tSFJIZ-Ah(-F AITMAVIT
01 txms,-,TJpermj ttcc)
\1111 Lb a principal place of business/residencc at:
—" w
(str�.t/ci ry/stia�c.�a p)
do hereby certify, under the pains and penalties of perjury; :hat
( �) I am an employer providing the following %vorkcr's cotnocnsaboP coverageLor my
employces Nvorldng on utis job.
I
(Insuran= Company) (P0Uc-.N'u--Lb,--r) --- (Expirmion Di?tr.)
1 O I am a sole props=,etor, general contraaor or homeow"Der (tide oee) and Lave hired
! the cono-aciors listed below vgbo have the ioilowi.og worker's co pokiest
i ..
i
(I+am of Co„^ciorl (InRrant: CotnDan)'/PobC; Nu1IILCt) Diic)
(Nzmc of Cooncor) (Lis-W-ancz C0mpan)•1PoUc—, Nu-mbc-0 Date)
(Name of Cowrano,) (Insur'ancz- Compan)-/Pouq- Namb`r) (Exoiraoo Datc)
1
(Name Of Comm tor) gnsuran(m Company/PoUcy Numb:r) (Expiration Date).
(.M.Cb_6dit C,=.j csc,::irate.-ry to itUC!u�iisfarn,�oa per+• to..rl eocr-.cat-3) -
a sole ro netor and bave no one wor'dD for me.
p p g
( ) I am.a home owner perforn=o all the work myself.
NOTE:plc=be aw-trt ts.-v.:}c bcmwwvcn w'ba cmptcy pc-iacu to cis r��,-.,-„ .,•7 �.;c.,ao c rcrau,•ofk as.d..clLy of
ant mat a”t}s r Umfu in urycb the botnoov uer r=d=or oa the ouac'.s gppurtev:rs theta r D �,Uy o�iderod w be
eitploycs u---the.. Lyon Alt(GL152.n 1(5)},=Pplicaboo by a boa=---=fw a 6c=--a Perna r=y--rd—tl:e
i
Ic-gs1 n_ti.,of ea ert,loyor uedcr d10 WorSccla Compamat AcL
i uadastaad dsa a copy orthi.euemam may bo ror�.vded to ttx Degertmeert artndusri.! office or tan..+--rat th.
oovemsc vaifcaioo and qui U-=c in t.==tovtrA;=Under sociioa 25A or MOL 152 mo I=d to the m oraimiazl P'16=
COali=�Xq of a fine orup to SI,500.00 and/«m orup to woe ycv end a,,-1 pcmlua in tSc roan or.Stop W.,�.orda• d
rian 0rS100.00 t day L piaA t�
For 6gs.rta�='1 u,c Doty -
�� permit Numbcr
h�p9 Lot '
Sigp.-ttum f LianscclPcnniucc e J
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Hold er: LS O rt� ;`
Name o ( \ License Number
Expiration bate
� -��1 -A b
Signature Tele one
gin s ered"l om` Irr o emen C nt c or:= s Not Applicable .❑
Company Name Registra on tNumber
Address Expiratio D
Telephon �� -��—1
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 buildin g permit.
Signed Affidavit Attached Yes...... No...... 0
1 x 1D
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 bomeowner.
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 buildinty 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 St of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF-'PROPOSED':WORK-(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs (ice] Decks [p Siding[01 Other[p)
Brief Description of Proposed
Work:_
Alteration of existing bedroom Yes �No Adding new bedroom Yes o
Attached Narrative Renovating unfinished basement Yes LLe!!fNo
Plans Attached Roll -Sheet
6a 1> I evi;usel t r dIrld#46 kil +g 1�o stli�i: a ru a wrnc:
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.AGEN7"OR iGON�It'ACTORAPPLtES.FORBUfL"`DtNGPERIVIIT
I, �j J�� as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work thorized by this building permit application.
at '0'lay.
Signature of Owner Date
I, Authorized
ent ereby declare that the state ents and information on the foregoing application are true and accurate,to the best of my snow edge
and belief.
Signed under the pains and penalties of perjury.
Signature f /Agent 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
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Vahanca/Fi been issued for/on the site?
��
NO ~�v�� DON7KNOVV �� YES ��
IF YES, date issued:
IF YES: Was the permit recorded at th Rei of Deeds? '
NO �� D
v�� um / Kmuvx xux
IF YES: enter Book Page! and/or Document#�
'
B. Does the site contain abrook, body of water ovwetlands? NO DON7KNOVV 0 YES
IF YES, has a permit been or need to be o btained from the Conservation Commission?
Needs mmbaobtained Obi x~=« Date~~� �_« ' �
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
'—
D. Are there any proposed changes toor additions nf signs intended for the property Y yB �� NO
��
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading on.or filling)over 1 acre n,io(t part cio common plan
that will disturb over 1acre? YES �^~�� NO �����.
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
ti
City of Northampton Starts fi ?' F
Building Department
212 Main Street `
- _ Room 100
Northampton, MA 01060
20S6onel, 1 -587-1240 Fax 413-587-1272
APPLICATION TOiONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE]NFORMATION'
This S6010rt to be compiefed b raffice
1.1 Property Address ,
��� �lh�
zor►e overt �stnct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Foy, F+jM%
Name(Print) Current Mailg Address��
Telephone T— „�
N1 IJ
signature
2.2 Authorized A nt:
Cu vent Ma"ng Address:
AM
Signature Tele one
SECTION ESTIMATED-'CONSTRUCTION COSTS=
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building �} �� �apBx�ilding Permit Fee
2. Electrical 1` (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 `o._
This Sectlon For Official Use Only
Date;-
Building Permit Number. Issued:
Signature:
Building Commissioner/inspector of Buildings Date
. a
BP-2007-0194
G1S#: COMMONWEALTH OF MASSACHUSETTS
*NOW CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2007-0194
Project# JS-2007-000293
Est. Cost:$2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const,Class: Contractor: License:
Use Group: MARK LANDY 131627
Lot Size(sq. ft.): 19994.04 Owner: KANE ESTHER M
Zoning: URA Applicant: MARK LANDY
AT: 66 FOX FARMS RD
Applicant Address: Phone: Insurance:
P O BOX 61 (413) 628-3203 0
ASHFIELDMA01330-0061 ISSUED ON.811812006 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 8/18/2006 0:00:00 $25.003066
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
66 FOX FARMS RD BP-2007-0194
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A- 154 CITY OF NORTHAMPTON
Lot: -001
Permit: Btlilg[[W
Category: BUILDING PERMIT
Permit# BP-2007-0194
Proiect# JS-2007-000293
Est. Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO
Const. Class: Contractor: License:
Use Group: MARK LANDY 131627
Lot Size(sa.P.): 19994.04 Owner: KANE ESTHER M
Zoning:URA Applicant: MARK LANDY
A T no F;.:);itt C-..iyi5 Fiu
Applicant Address: Phone: Insurance:
P O BOX 61 (413) 628-3203 Q
ASHFIELDMA01330-0061 ISSUED OAr:811812006 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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: 01< (7-jr-O&
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA N OF
ANY OF ITS RULES AND REGULATI NS.
Certificate of Occupancy �' Signature:
FeeType: Date Paid:"'/Amount:
Building 8/18/2006 0:00:00 $25.003066
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Conunissioner-Anthony Patillo