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�. DEPARTMENT OF BUILDIj\TG INSPECTIONS /
INSPECTOR 212 Main Street • Muuicipd Building
Ncuthwnptoii, MA 01060 ;any
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to
act as l.is/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 twofamily-
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 fegulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings(before bac!iEn
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
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F}o 0ti� (riff .Pf �'Tarfl�allt�fo��
P ' E .51LS.icthnsclIe-
4 o DEpARTMEIJ7- OP DUILOFNC INSPECTIONS '
212 Main Strcet ' Nfunicipal Building
Northampton, Mass- 01060
WO1U<3 R'S COIAPENSAg7ON MSURA-NCE AI�I�I1�AATI"
i ccvsxJpczuz�ticc)
%I,rlth a principal place of businessfresidence at: — --
(sar-t/ci tr/scaulzi p)
do hereby certify, under the.p?_ins 2nd penalties of pcguF, -.hal
( ) I am an employer providing the followine'workcr's coinocns_n:jon cove 2ge for Iny
employees ivorking on this job:
(12sur�=Comdr-r) (Petit:Nt= r) -- (r:piraor D2cr)
( ) I am a sole proorietor, general contractor or hoa-ieowoer (ci:cie one) and hzve hired
the contractors listed below who have the foilo"vino worker's compensation pokie-s.-
(itillIIC 0. caaml ior) On-suranc- Coinpanyill o c ? wm'-,C:)
(Name of Coacacior) (Lis-a=c: ComoazvRoUc-, Nuncrr) (Expirdon Date)
(Name 01 Conn-aclo:) Gasur-nc= Com=)•/Policy Number) (Expii dos Daic)
(Name of Coatmctor) (Insurance ComoamyfPolicy Numb-J) (Expiration Datr).
(mach zd1i-oc=1 dcC-dnccc --v to tnfornajoa P-ruining to.11
( ) I am'a sole proprietor and bave no one worldDg for me.
( ) I am.a home owner performing all the work myself.
NOTE:pl=-=be awzre Lfii�j,,je bcm,=o�ver�.to ezapioy Pe=o=to do - c===,00 C rraII wvf-k on.d%,�L-;:of
alit cac"ib--=dl i,=t=?a to whxh the bomoownc raid_,IX oa the aaancts 2,purtcn:.�tbe�n LT ax C-- .1Xy eea:d.--cd to be
--PIcycs 11 the---kze--c=�-k---''oa A23(GUI S2-=1(5)�spplzanon by n bomtba-oc far-lica_or Pamir r=y'"d—LL-
Iegs!eta us or=e=,loyec uoder da Worlcdc C npomatioa A,�,-
[uadcziLnd tha a Dopy of thu mtemcca a y bo for-worded to tba Depertmrat of IndaasriJ Acs A--,OIL-of Irta—
oovc sxb vG1fielioa and t}u L•iliac w senor:`covcist�e t>adr.1 soetioa 23 A of hi4L 151 on Icd to the i , 2ioa o(cimiac!pea�io
e0a=M3g of a tint ortp to 51500.00 utdlor j'uo�of up to Doc ycr Lod Cj,l pco Pjjn in be form of a Stop Work Ordc Lod L
fire o(S 100.00 s d_y Lpuayt me "
For fcp<rta'=a�u,c Drily
PL-rmtt Numbs-
Lot n -- -
S i mature of Lia=isc&Pc nni ucc J
SECTION 8-CONSTRUCTION';SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ! C`Lt '-z i tVi'jt f ? }f
License Number
Address / Expiration Date
Signature /// Telephone
9-, Rein`iste-f eil°Ffiomeslmpriiveirienf Confracto Not Applicable ❑
Company
Registration um
Name er ---- —
Address Expiration Date
t, , Telephone iL-5W/
c s.
SECTION 10 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.-c.152;§r25C(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 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
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check ail applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing [�
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [E3] Decks [p Siding 100 Other[01
Brief Description of Proposed
Work: Y - L/ 7-G� / C :3/N:�C.t"9`x r,-,,'J' ���t <F'f•.nt�t ,�-�,('c"rr" l- rft. `�/ P '1 ¢ ,�- p"
Alteration of existing bedroom Yes _ No Adding new bedroom Yes _ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
fia_If New hcii se and ar�addit ,111.1 ffaffiou sm cW-com p�efetfhe aEfawincl:
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 AGENT OR CONTRACTOR APPLIES FOR BUILDING:PERMIT
,,- as Owner of the subject
property
7 `
hereby authorize e /I d
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner . Date
as Owner/ thorize
en .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 per'ury. '
Print Name
Date
Signature of Owner/ i !.= `/
Section 4. ZONING All Informatioh 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 I
Setbacks Front ( I
7 ----
Side Ls` R' L: R
Rear
Building Height -- r-
Bldg.Square Footage % (-
i 3
Open Space Footage %
(Lot area minus bldg&paved
-kin
#of Parking Spaces
Fill:
I
(volume,&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES Q
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 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 v4i DON'T KNOW Q 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 Q NO
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 Q NO [�y�J
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
f Nort ampton
ng Department fur '
2 " Main Street
oom 100
N ""5 pton; MA 01060Aone 41387- 240 Fax 413-587-1272
G7the�S'pec�fy
, _ � t..i+r •.: ,emu. ._..._. ... ...- {
APPLICATION`Tt�'LiI' 'FRt ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This."section to 6e completed 6y office
ZoneOverlay'Di stnct
Elrn St Distr►ct GB District, .
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Adds:t
Telephone
Signature
2.2 Authorized A gent: /
A?i"C41 t
Name(Print) Current Mailing Address:
c
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building •� y (a)Building Permit Fee
2. Electrical �i �`_' (b)Estimated Total Cost of
Construction from 6
3. Plumbing �rZfy� Building,Permit Fee.
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) t} <f'r- Check Number Q
This SectiorrFor Official Use Only
'Date
Building Permit Number.` Issued:
Signature: r
i
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0454
APPLICANT/CONTACT PERSON RICHARD NETTO
ADDRESS/PHONE 167 SOUTH ST#6 NORTHAMPTON (413)582-6985
PROPERTY LOCATION 29 KEYES ST
MAP 17C PARCEL 147 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: RENOVATE 1 ST FLR KITCH&BATH INSTALL REPLACEMENT
WINDOWS REPAIR TRIM&CLAPBOARDS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 086824
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRfIATION 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 C ssion
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.
29 KEYES ST BP-2005-0454
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 147 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0454
Project# 35-2005-0601
Est. Cost: $30500.00
Fee: $135.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin RICHARD NETTO 086824
Lot Size(sq.ft.): 10367.28 Owner: CHRISTENSON MARY E
Zoning:URB Applicant: RICHARD NETTO
AT. 29 KEYES ST
Applicant Address: Phone: Insurance:
167 SOUTH ST #6 (413) 582-6985
NORTHAMPTONMA01060 ISSUED ON:10121104 0:00:00
TO PERFORM THE FOLLOWING WORK.-RENOVATE 1ST FLR KITCH & BATH, INSTALL
REPLACEMENT WINDOWS,REPAIR TRIM & CLAPBOARDS
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:
FeeTvpe• Receipt No: Date Paid: Check No: Amount:
Building 10/21/04 0:00:00 1014 $135.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo