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4.v DEPARTMENT OP BUILDD\IG INSPECTIONS -
212 Alain Strcct Municipal Building
?Northampton, Mass. 01060
WOMCER'S CONIPENSA'nON MSURANCE Al=, :I,,.ArjT
(lic m,—s-j[)crmitfrr)
plzncipal place of businessfresidence at: —-
(sa-�t/c�ty/staula D)
do hereby certify, under the paint and penalties of per3ury, .hat
O I am an employer providing the following worker's cot:npcnsc:JoP coveMSe for Iny
etuplovecs woridng on ties job:
(L,uti n=Coozacy) (Pc1ic:Nu-mb-cr) -- Cr:•pirtiorr Daiz)
os"le prooret neral contractor or homeowner (ciicie one) and have hired
t-he coon-actors listed below wbo have the follo�viag worker's comoen_�zaon pa!icies:
("Namc 0. con. Gnssumnc-_ Como3n)YPOUCi Datc)
(Name of Cooczctor) (lns,uanec Comoanti•IPotim, Number) F»ir lion Dare)
(Name o(Contrdao,) ([n_suiance CompanyfPotiq- N;imbj) (Expirtion Datc)
(Namc of Contractor) (Lns'uraa� Comrany/PoUcy Numb•r) (E�p 6oa Darr) .
(a¢ _d'!i Deal deC,tf ncGaar)-to u—?uZc raforta 0.P� to.17
( am a sole proprietor and have no one worid.ng for me.
( ) I am.z home owner perfori=g all the work myself.
iNOTE:ptc=c be ewim ts.•wt .lo bemeuwvm+t- o carploy peom to do .s- =s:.Goa c repair work oa,d..elLi:of
aot mocr tb L-ce tail iu"'-eh the bornoo-w<r raedo cc oa tic g oun zpputtena.^.tbecn err ax C� Zy oc=d- d to be
cavloyesuse
the kvid: - -*m Act GLlS2�l S
( ( )),:.pgU=ion by a bomeoamc for c bc==_cc permit rr_y nidmcc the
Icgsl craw of e.a mom.loyoc uadec d> Woe ,Compooz..tioa.AcL
[uadesz—d tbt.>oopy of tbi.-a=e my b<roc-,yarded to do D,,_,_c,,of IucSaxric!Accdc i'Offioo or roe d-
coventsr rcirctioo and Ut L f�ltac to secure eovery�tmdes s«cioa 2 S A of htQL 152 eaa Ied to the imposIIioa of aimiai!pen ltic
ooa:lzm of a fiat orup to S i}oo.00 utdloc ixaiy�of up to ooc yr_r ead a,il pm,h.io be form or-Stop Wort;ordc ead a
fia�o(S 100.00 a d_y c�tit t>x
�... Foe dcp ra>,1r v.o cedy
t c mtt Numbcx
N/cap: Lot u :
sip-tun of ic�sc Crrrxiucc e J
~ � �R54RCh3t4[tt$ -
DEPARTMENT OF BUILDINIG INSPECTIONS �=
INSPECTOR 212 Main Street i Municipal Building
North,unpton, MA 01060
,r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act aS his/her construction sups: z.,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 famiry__-_._
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 r',egulations. 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.
T�*ho t,nmo� rmnr},ircc nflcr trnrtac to narfnrm xvnrL- PIP!trt(`Al
it ai�, uvau�.v rr u�a iu vv vaiva a u.uv., w nhimhina,9r aacl tha
t. - . . . wv .-1 Y_ ._.. 1 -
a....,/ ____
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
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor�Jt� Not Applicable ❑
Name of License Holder: ��
License Number
a/
Ad Expiration Date
Signature Telephone
Rectsfered$tfiome fifiprovement Contiractor4 _ Not Applicable ❑
Company Name Registration Number ---
Address qU Expiration Date /
Telephone ` ` �S f Ze xV6
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
u
The current exemption for'homeowners"was extended to include Or:ner=accupied Dwellings of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire who does not possess a Icense,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
f
SECTION 5-DESCRIPTION`OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ . Replacement Windows Alteration(s) Roofing
Or Doors E]
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks (M Siding[0] Other[0]
Brief Description of Proapsedd
Work: 1,V !T'v �c�� `/�/
Alteration of existing bedroom Yes No Adding
new bedroom
Yes No
Attached Narrative Renovating nfiin sh d basement
V No
Plans Attached Roll -Sheet
lia Nev .�ia�rse ancorcd�to�tcxls#irietousna:n�arxrpiee-fi ` fonct:
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT.OR CONTRACTOR APPLIES FOR'BUII DING.PERMIT
r
I, (� r? �--- as Owner of the subject
Property
hereby authorize avn
to act on my behalf,i al ma lative to woK aifthorized by this building permit application.
Sign re Date
1, dh�'/ l/'�-t t�,� /(C �_ as Owner/Authorized
Agent hereby declare that the statements an ' ormation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
41 eyla-p v�
Print Name
2s � �
Signature of Owner/Agent Date
` ~
'
. .
-
Section 4. ZONING All Informatibri 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
Setbacks Front
Rear
Building Height -7
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume*Location)
'
A. Has a Special Perm it/Vuhunue/Fndi ng ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0 �
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON-1KN V-VV' ��
IF YES: enter Book Pagei and/or Document#
�� ��
B. Does the site contain a brook. body of water orwetlands? NO �_��� DON7 KNOW �~� YES �~�
IF YES, has a permit been orneed to be obtained from the Conservation Commission?
'
Needs tobeobtained xr� Obtained �~� Oote ]ssumd�.
�~� �_/ '
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES0 NO
'
IF YES, describe size, type and location:
E. Will the construction activity disturb grading .nr filling)over 1 acre orisdpart of a common plan
that will disturb over 1acre? YES r NO (D
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
f �
-XI -0partmenttrse onl _
City of Nortf�ampton Status:orvermtt F
Building Department rrt C tieeer�nnif q
212 Main Street Sewet5ptrci�Vta5�t� e
Room 100 afererlatiTrtj
Northampton; MA 01060 bra ets ofStr#ttcturaPlans � "�
phone 413-587-1240 Fax 413-587-1272 PtaSite Pfanu
r
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
3_t � `,
SECTION1.-SITE INFORMATION C!"',
This section-to be completed by office
1.1 Proverty Prove Address:
ZP
A(� Lot E1n�t
Tone
f,-.; Overla Dtstrrcfi
Y ,
SECTION 2-PROPERTY'OWNERSHIP[AU"IWORM-ED AGENT ,
2.1 Owner of Record: '
�*p-N 6c�I'itJ S i
Name(Print) Currrt Mailing Address:
PlI Z-p,��Nr�� A) 07&Z
/-ire) . �71,E ��G Teep�on�c �'?S ��I Z y — 4s 342 40 0
Signature ?4
2.2 Authorized Agent:
Name(Pr' Current Mailina Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 51 01-v.a (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=0 +2+3+4+5)
Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2005-0741
APPLICANT/CONTACT PERSON ROBERT SPELMAN
ADDRESS/PHONE 71 NASH HILL RD WILLIAMSBURG (413)268-9452
PROPERTY LOCATION 123 AUDUBON RD
MAP 05 PARCEL 016 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid to
Typeof Construction: CONSTRUCT BATHROOM IN EXISTING
New Construction
Non Structural interior renovations
Addition to Existing
AccessoKy Structure
Building Plans Included:
Owner/Statement or License 082172
3 sets of Plans/Plot Plan
THE FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9104ATION 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 Stre ommission
cam Z Z oo�
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.
123 AUDUBON RD BP-2005-0741
GIS#: COMMONWEALTH OF MASSACHUSETTS
MW:Block: 05-016 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTP.ACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category BUILDING PERMIT
Permit# BP-2005-0741
Project# ]S-2005-1037
Est. Cost: $3000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ROBERT SPELMAN 082172
Lot Size(sa. ft.): 25918.20 Owner: DELEVINGNE LIONEL
Zoning: RR Applicant: ROBERT SPELMAN
AT: 123 AUDUBON RD
Applicant Address: Phone: Insurance:
71 NASH HILL RD (413) 268-9452
WILLIAMSBURGMA01096 ISSUED ON.
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT BATHROOM IN EXISTING
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—�—O� Rough:2 1)y 1 House# Foundation:
Driveway Final:
Final:.-6. ( Final:
01119�,w Rough Frame'
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: FinalC 3
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATIO OF
ANY OF ITS RULES AND REGULATION
Certificate of Occu an � Si nature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 1/28/05 0:00:00 181 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo