17C-171 (3) \
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DEPARTMENT OF BUILDIJ1G INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '
Nortli,vnpton, MA 01060 '°'~ ' •`'
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act aS has/her construction sups: , 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."
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&, 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
4,4 7— 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
B eti �If� of �,TRrfljamptoii
uanchnsrlta' _
p DEPARTMENT OP DUILDr),C INSPEC'r101,,S
212 Main Strect Municipal Building
Northampton, Mass. 01060
`VOMCLR'S C01MII ENSATION IIISULZA. C'F_ AF=, AVIT
pl ccnsxlpermjticc)
��7th a principal place of business/residencc at
(pnonc:')
(st t/c1 ty/statda p)
do hereby cerdi ,, under die p?-in5 -,ad penalties of perjury; ih.1
( ) I am an employer providing the following v,-ork&s colnncnsado, cove��c for Iny
employees worlang on tills job:
i
(Lusu.ran=Comrz-m,) (Pclic: ?:u.-nir_r) (r;-piraor. D2j--)
I
( } I an a sole proprietor, general contractor or homeowner (ciicie one) and have hired
the contractors listed below wbo have the fotlo%viog workers comptnsaison policies:
i
('NIM: Of Co_`.rncwr) (In urancc. Colnpali)-i�o6q- (-XJlrauon bate)
(N.1me of Contractor) (Insuraacr_ Compaayi?ofic \-;uni cr) (-Exvir,-don Date)
(Name of COntractor
r ) (Ins'urancc CoLnpa.n}-/Pobq- tv;>.tnber) (E.rpirtien Datc)
(Name of Contractor) gnsuraacc_ Company/Poliey Numbc-r) (Expiation Date).
(aasdi d!taoc7l rscc,ifnoccz.ry to inGvd;inform'Lzoa pcnaiaius 1..L ooa=-_cnt-s)
{ ) I am a sole proprietor and bave no one woriang for me.
I am.a home owner performing all the work myself.
NOTE:plea be eovarc tx of_1c bemeo•�OCfl Kbo employ rx saai Lo(17 C=.ZeaOo c rrnu-ori on a d-. L1-,or
Got awes III= z-tmry is wbicb the bomooly-oct rich or oa tb.e pbunca app rttcb z7 lbeto wr ax oeaidTcd to be
-iVIOyas urea the-ad`s c=p=:. ioa Act(GLI 52-=1(5)�zppU=L6ao by a bomeoa-ocr far c Ilex_or txnna=y C%46=-tLC
legs!n-'x.•of as=ployac under d! Wocic,ora Coaspom,tion Ad
I uodcrna d rhs a copy of thin c=cmocd may bo forwx jed to the poporemea2 orio&. id A=dortu'ofGoe or Imraooe foe tie
covcr� vc Lc=ion and tb1 f:-i11ac to zo=m)cove%6�tnndc soQioa 25A of 1.toL 152 can lad to the isrposIIioa of cimin.s.l pca+W'=
oc-=%Lxig of a{roc of tP to S I,S00.00 ardor y orup to ooc ycar=d Civil pma-t m io tx form of a Stop Work Order sad a
rim 0(S100,00 a dsy Lpiatt me
For dcq.rtaa=-''t u-only
1v(ap=
Lot n .
''sit�tu> orLiO=n_-x_-_1PctM�ucc ��e _j f=
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9 teQistere ;i om lriroprotie en Coniracto ! 41
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Officials 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
SECTION 5-DESCRIPTION OF=PROPOSED`WORK(check all applicable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors Cl
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [M Siding[0] Other[pj
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a.iftNelnr�o�se�andaracldltior�to,�exrstlng�ouslg.,vcnmp a e=#�ae:.t'oTl'�o'wlna:
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 heatinc? 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 conlonn 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.#OR'$UILDIN[G PERMIT
I 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
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. b vi
Print Name _ r
Signature of Owner/Agent Date
u `
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 y {
Frontage _-.-
Setbacks Front
i
Side L R: L: R:`
F-7 pl-
Rear I-----� L�
Building Height --- / /
Bldg. Square Footage % ---
I
Open Space Footage
(Lot area minus bldg&paved
parking)
' I
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Perm it/Variance/Findin ever been issued for/on the site?
NO Q DONT KNOW U YES Q
IF YES, date issued:(
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
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 Q NO
IF YES, describe size, type and location: xi
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,a cavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
C
Citof Northampton
Building Department
`L
<,9
Main Street
Xorthampton,, Room 100
Y MA 01060 m
f, Fa 413-587-1240 Fax 413-587-1272
APPLIGQATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
'; Thts section to be completed by office
1.1 Property Address:
����.-��Cw�. �.,r t � �,,., �tom, N►aP-� �t' UA�t
"r O t L 'tc�ct
s. r sn ar:
Elec SY Gistri'ct CB'Aistn:t
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: f (� 3l''?" �;,f .k r'; �..t y I s
Name(Print) Current Mailing Address:
{
Telephone 1-1C {
Signature
13 - 5 K .;
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION'S--ESTIMATE6 CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building,Permit Fee
oc ! " �.N �[.,
2. Electrical (b)Estimated'Total Cost of
Construction-from 6
3. Plumbing Buildinq Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) CDC} , C.} € Check Number
This Section For Official Use Only,
_Date
Building Permit Number. Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2006-1223
APPLICANT/CONTACT PERSON ADKINS EDWARD T&ELIZABETH S
ADDRESS/PHONE 26 SUMNER AVE FLORENCE
PROPERTY LOCATION 26 SUMNER AVE
MAP 17C PARCEL 171 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction: REPLACE 8 X 8 SHED
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 F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 S Commission
��1�
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.
BP-2006-1223
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-1223
Proiect# JS-2006-1817
Est. Cost: $700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 11020.68 Owner: ADKINS EDWARD T&ELIZABETH S
Zoning: URB Applicant: ADKINS EDWARD T & ELIZABETH S
AT. 26 SUMNER AVE
Applicant Address: Phone: Insurance:
26 SUMNER AVE
FLORENCEMA01062 ISSUED ON:51I812006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE 8 X 8 SHED
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 5/18/2006 0:00:00 $25.004567
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo