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s DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '>o
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 his/her construction sup.,_,:.,: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." j
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 j
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, 6 t- ,c- — S C, ,rd 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 1Z As 10 3
Address of work
location
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y (1,iftt of cL1ar ljt'tllipf(III
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^z L)EPfum-mEN-r Of, EzmiwI�G INSPECTIONS
212 11Tain Street , Municipal Bull 11Ilg
Northampton, Mass. 01060
W0RICER'S COMTENSA`I'ION INSURANCE A + t AVIT
1,
�:rith I principal place of busiress/residenc�
(�phofle.";t
do hereby CerL'Uti;: Lnacl LhC r)aiilS lliiti pCil it]CS 01 peglll}',
I am an employer providing the rollo'.'.''iI—, '. or}_cr'S compensobo1] For my
elilployees wo6drlg on t?lis job:
(InslranG Com m) -lice;N Turn be r) ---- (F�p;r aen D2tc)
l I aril a sole proprietor, ;general c-�n c or - h0IIiCOIN-ler (c, Cie one) and, have hired
t_ Contractors listed belo � ho ,:_.,, c is � e j - e
',-� ;, th `oi .il: ��rorl�... s coca p n�:�on ��.. .
(I`me of Nwnbcr) (T?:%:r%tiCi: Ddtc)
(Name of Contactor) _ (71LSUr nc Com�z,:v�Pc!ic Number) (FLXD ratios Date)
(Name of Contractor) D tc)
- (Name of Contactor) _ (Insura.ne-, Comp. :y/Policy Numb,--r) (I,?,ri-:tio Date)
t atLlLt:-d'�1�]CC:i]S::�Ct:...___.. ::l:.�_1'.� ..:'ti:':1-:Wit'.�-...._...::1'f-.. .1i l:(::_:�i:••,�
1 -ull ?. OIC l?IUllrlCCOi 2i1'1 i1LaVC 110 oil'-- YOf nleE
pleas-tic at a c tlst.ttilc b<nc:�u2rn.r,-o rnp1 y;r. <. utc�a.an G cr:-pair I'll!),_.._
not Mccc thaa d=co utu's in\i{:-'di;.tic 1;�-:ti>>.tZ r-a:,::�a a;'`�.:4.:r_:.s a urtcr..:r.2 ihcRC a:c n.:t GCTYS1I1y a!::'t;c:-C:o
(511,' ""'1C:;i1v a 1:Ot'1Gb t4'tXl!C7 L 1,r=-zc c<p;.rnni::-
cw.ployc�uts�,cr t}r tvct?•'.-fa ar K•--: ::n��r: Gi.15?mss? ...t:�.---.. .... ._
legal rtatuc of nn Quployx under t o Wor c1a o l;xrr anon:A c
I undc-•,t, d that a copy of the ciat=1: 1 Mvy bo forw,vciod to tl»LY,j rt_z,c:Y:of Indv -riJ Mzd�:y Ciucw of for tlx
coverage verM=ion=td t1Lt f_-dud to!=,rc llI:3'::4c'uon 2SA of Mot.152 can Iced to the i.np.xifia-t r f c i 1 vc,41=a
couaisting of a fur_of up to S 1.300.00 art:'Y in:;rivr t1;_nf;.p to Cr,. in yc fl n C.f.,Sic;+ Y'c Y 0,-\,=_rA a
fir.:of 5100.00 e dsy
For dr;:uvtratai uie oily !
Ycrtnit Nutntz:r ___.._. _
JlrnntllrCUP:.iC�1';C'ahCCltt;i(r_.'� _ ...._rii=T'' i
SECTdgN 8 CONSTRUCTIQN SERVICES
4
8 1 Licensed Construction Supervisor: Not Applicable ❑
i
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
N Reg_s ere I drn mb ouemelit ontracto Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SEGTIQN 10 1M1IORKERS' COMPENSATION INSURANCE�AFFIDAVIT(MG:L.,c. 152, § 25G(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-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 far 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 Local Zonino Laws a Stat assachusetts General Laws Annotated.
Homeowner Signature
SECT90N MOT WORK c:'eckafl a lira �e u
New House ❑ Addition ❑ Replaceme t Windows Alteration(s) Roofing ❑
rs
Or Doo
Accessory Bldg. ❑ Demolitiong New Signs [ ] Decks [ ] Siding[ Other [ )
Brief Description of Proposed Work: 8da AAA A 00',x.. +
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll D - Sheet 0
6a fi t.eW�to.0 " z trs d fle trp otoTes h.oas"rng�; co 1e 'e the fol.l`ow�.n:
a. Use of building: One Family _ Two Family Other
b. Number of rooms in each family unit: 3 Number of Bathrooms
c. Is there a garage attached? N
d. Proposed Square footage of new construction. Dimensions
e. Number of stories? '7
f. Method of heating? �c c e-C a ,<- 6,zS)L— 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 x No. Is construction within 100 yr. floodplain Yes X 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 X
SEC 10 YVN�ER�dT IOR.ZAT101V TO.BE COIfII: jr WHEN
OW�f�S,�'1GE �� ONTR�AC70R APPLIES FOR BUILDING PERMIT
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.
Signature of Owner Date
r �C,--'C"C� 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.
S
Print Name
l5
I
Sign ure of Owner/Agent Date
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Section 4.
i
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
i
Lot Size
Frontage j
Setbacks Front
i
i
Side L: R: L: R: f
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
i
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T 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:
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
,.phone 413-587-1240 Fax 413-587-1272
APPUCAT70N TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.i Properly Address: fio be cflmplet bT office
a �u r
19 �s9
W e�C �' BxM n,c °yr ,7 ■''"`' + fir, r i ,�,
�NG.3(
.............. H ar^
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SECTION 2.-PROPERTY`OWNERSHIP/AUTHORIZEDr ENT
2.1 Owner of Record:
Name(P5?*) Current Mailing Address:
Telephone
SigAdLUFe
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-:ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be
9"l-Use Only
completed b y ermit applicant
1. Building (a) Bwtcing Permit Fee
15 GU
2. Electrical M fstir nated,Totaf Cost of
C} :Construction froi- -.6,
3. Plumbing 7 5 Building:Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2 + 3+4 + 5) y 00 C� Check Number This Sectibih for'Official.Use Only
Building Permit Number: SOY' � TDate Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-0692
APPLICANT/CONTACT PERSON ALSTADT KAREN A&BRIAN BAIRD
ADDRESS/PHONE 84 CHESTNUT ST FLORENCE () 584-8374 Q
PROPERTY LOCATION 84 CHESTNUT ST
MAP 17C PARCEL 158 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out 41 Cgq
Fee Paid :
Typeof Construction: ADD BATHROOM TO 2ND FLR
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
INF9R<ATION 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 mission
loo
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.
84 CHESTNUT ST BP-2004-0692
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 17C- 158 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2004-0692
Project# IS-2004-0990
Est. Cost: $4000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use croup: Homeowner as Contractor
Lot Size(sq. ft.): 6185.52 Owner: ALSTADT KAREN A&BRIAN BAIRD
Zoning: URB Applicant: ALSTADT KAREN A & BRIAN BAIRD
AT. 84 CHESTNUT ST
Applicant Address: Phone: Insurance:
84 CHESTNUT ST 0 584-8374 (�
FLORENCEMA01062 ISSUED ON:12116103 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD BATHROOM TO 2ND FLR
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 Shmature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 12/16/03 0:00:00 246 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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84 CHESTNUT ST
BP-2004-0692
GIs#: COMMONWEALTH OF MASSACHUSETTS
Lot: -0 1 17C- 158 CI'T'Y OF NORTHAMPTON
Lot: -001
Permit: BUi ft
Category: BUILDING PERMIT
Permit# BP-2004-0692
Project# JS-2004-0990
Est. Cost: $4000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class_ Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 6185.52 Owner: ALSTADT KAREN A&BRIAN BAIRD
zoning: URB Applicant: ALSTADT KAREN A & BRIAN BAIRD
Applicant Address: Phone: Insurance:
84 CHESTNUT ST ( 584-8374
FLORENCEMA01062 ISSUED ON:12116103 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD BATHROOM TO 2ND FLR
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
, 7 Footings:
Rough: $% , Rough: ;'' f House# Foundation:
-0y Driveway Final:
,� .q �.
Final: ',a Oy Finn: �•
V/y A Rough Frame:
�a 0 d/0)
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: `
Insulation: -
Final: Smoke: �y.._
Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OFNORTHAMPTON UPON VIOLAT N OF
ANY OF ITS RULES AND REGULATIONS.
CertlfCate Of OCCU anC Si nature:
FeeType: Receipt No: Date Paid: Check No: Amount
Building 12/16/03 O:EI0:00 246 $50.00
r
212 Main Street,Phorfe(413)587-1240;Fax: (413)587-1272
Building Qummissioner Anthony Patillo