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,. DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '>a
Northampton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as i is/her construction sups: .:sor. T he state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fanuly
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)
n r � i i n _ � L_.[1 _.` 1:.��1.e 1..-.a rtnn n�rmit
1 Will call to schedule all leyult ed bulluing irlSVUk LLUi13 iieCcSSai y .vi.LAZY
issued to me.
Date
Address of work
location
pF `tiL >1fl3arfll�z))1}�tnit
1 r w ` r�t7ilt(h RL(IIO-
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w DEPARTMEI-rT OP IIUILDrJ\jC INSPECr101:S ;
212 Main Strcct ' Kunicipal Building
?Northampton, Mass. 01060
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WGIUCERIS C0 1YIPE rSATIO N
GNSURA-NCE A=AVI7
(liCCtL�.xlpctm�ticc)
V.ith a prilIcipal place of business/residenc-, at'.
0p
fVl-fiecbt rAA (Fhonc') 374`�r
(sn-�tici rj/stalcln p)
do hereby certify, under thc.pains and penalties of pc
rJury; hat
( ) I an an employer providing the follo%ving tvork-&5 comocnsaoo, cove SC for ln),
eloployces worb.ng on Oils job:
OM-a--n=Conracy) (PoUc: Numir_r)
( ) i am a sole proprieror, general contractor or homeov,'ner (c cie one) and have hired
the contractors Gsed below r bo have she follow' worker's comoen_,26on pe>icies:
([+1IDC Oi GO„_ Ci0") (In-suranc; Coinpx1)Y-PoUci ''rube) (tCpiFJRon Datc)
i
(N,mc of Conlrczor) an.SIUUCC Comoanv/PoIjc- Nu in-r) (La-virrion Date)
(Name of Connaao:) (Insurance C.oMP2z)-/PoUq- Ntlmbu) (Expimdon Da1c)
( 1ianC—c Comrai?y/Poticy Numtrlr) (Espii-anon Dau).
�.•�..... w wuuauor
, (atia.ch-d�t.:ociJ�ca.ifncoa.�_^}•cc a�c?u�iaforn.�oo pertaiaias tv.i!ooa�-_coca)
I am 'a sole proprietor and have no one working for me.
( ) I am.,a home o%vuer perforn ing all the tivork myself
NOTE:plea be atM Ib-l-1Jc bcmr�vcn ubo splay p•��to rSo c i^s e• �c=--= oo r rtp=-ori oo.d- � -c of
one caoce tha tt�o t tip is«�it�the bomoowvc resda a ea the IIouac'a z�puten_rs tbeao e r we�_-_1}y c,-=. w be
ccaployc7 uaea the..uirls c=np�ca An(G L152,=1(5)�.a.pptinDoa try a bomc,aa fcr a bc-�_cc pema!>_y c%id=Doe tie
1 Ic-P1 cLIa-of as e:,loyec coder t'bo Wor'coea Gocagema,tio net_
I vad°'a d tb+2 a oopy of Lb;, be rot-+.nrde.d to Lb.Dcpnnmm¢or IOd r w t,-d=Ly om-.r hair—for tb.
covcrxce vcriGeaioc end that[-ihae to A==tovct nee und'7 sozdoa 25A of}.tdL 15-2=1ed to the i=pairtioa of cua:.,.t pczL 16m
comisiaE of a rMc orup to 51 00-00 ar,6101 ca>pri7o orup to ooc ytar t.od ovil pm.itia in tSc room or.Stop Work Ord,-- aad a
G=of S 1 x d_y Lpl=
r
Foe.t ,.n,.._.,t u.e only —
IJ ' `j` c?l L,/ PcrmT[1�umtxr e
C' Lot s.
S i or Lia--xuecJpc tnti tics j F
SECTION 8-CONSTRUCTION'SERVICES
8.1 Licensed Construction Supervisor: D Not Applicable ❑
Name of License Holder: �,+�M�S Fyss 6 4&6
License Num er
i p � 4 1�. 1- i c�c j� OA , C��oG�C, G 09�r �2odG.
Addres Expiration Date
Signatle Telephone
Applicable .❑
9 Registered.RomelmproVementGoiitrao � �M;
Not A
136 32 7
Comeany Name Registration Number
.fix �� , /,till���;� 1"14 /6 9� ��k�a�� g
Address
Expiration bate
Telephone 3,�r-7��-Y
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...... ❑
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-vear 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 resuiting.in Deaui)of use;fassachusetts General Lai xs Annotated,yon 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
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 [O] Decks [p Siding[D] Other[❑]
Brief Description of Proposed N'ii"
Work: '-rla i P oL. s147" FS, �Lyr�anJ z� fCoc�. rxa ra /i`&An C,41vb Fly
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
�. ia?;�^'-�1�°'�. ".rz-
sa If Ne�nrhoase angora ditior to xts#inu.hnusli�g.:cornple�Ee-*tfil 461 lov gnu:
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--OWNERAUTH0 RIZAT ION.-TO BE.°COMPLETED WHEN
OWNERSAGENT611 CONTRACTOR,APPL'I.ES.FOR!`rBUIll GPERMIT
as Owner of the subject
property
hereby authorize b37q � OIL [)c�P_S
to act on my behalf,in all matters_LWative to work authorized by this building permit application.
y
"_S,gntAU1WreZ;_,f:0i_,ner Date
I, 7� S �- �c�ss ,6)A B oLPf RS 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.
r---
rc'S
Print Nam
Signature ff Owner/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
Building Department
Lot Size
Frontage
Setbacks Front
Side L:!— R: L:' — R:_
Rear
Building Height
Bldg. Square Footage
Open Space Footage % ---
(Lot area minus bldg&paved i
parking)
#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 Q DON'T 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 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 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES N0 n
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 �
Departmentuse-only
City of Northampton StatGS ofPerr�a�t `
Building DepartmentarkGut[ , ,naa � rut
2 t2 Main Street s weds tc aua't lty X "O" k�,
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Room 100 Water ��tlabr RIP,
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Northampton, MA 01060
Cost arts � r
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hone 413-587-1240 Fax 413-587-1272 ,
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
x
6_10 �-'�c+ (J�w v���� ,N(ap Lat Urut r
G S Zone Overlay iDistr ct
Elitist Dtstrtct
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
J
Name(Print) ^ Current M I re 5
ids=' Telephone
Signatur
2.2 Authorized Agent:
Name(Pri, ) � Current Mailing Address:
7 .�� 413-371--Xif?5
SignaturE Telephone
SECTION 3-ESTIMATED CONSTRUCTION:COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building i (a)Building Permit Fee , DO
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. Date
_ -Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2006-1014
APPLICANT/CONTACT PERSON JDR BUILDERS
ADDRESS/PHONE P O BOX 66 WHATELY (413)665-7587
PROPERTY LOCATION 670 HAYDENVILLE RD
MAP 06 PARCEL 001 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
- A ildin Permit Filled out
LI-Ke Paid
Typeof Construction: Strip ply and reroof
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF. OR1y1ATION PRESENTED:
pproved 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
v3
Signature of Buildi 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.
BP-2006-1014
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:81ock:05� CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit#
Project# JS-2006-1501
Est. Cost: $5250.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JDR BUILDERS
Lot Size(sg. ft.): 612889.20 Owner: FENTON THOMAS J
Zoning: SR Applicant: JDR BUILDERS
AT. 670 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
P O BOX 66 (413) 665-7587
W HATE LYMA01093-0066 ISSUED ON:312912006 0:00:00
TO PERFORM THE FOLLOWING WORK.-Strip, ply and reroof
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 $25.00276
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo