22D-006 (3) �'StiAAfPT
g=o oy� (rxfp of Xort4a ipton z
� � �assachirsctts �
DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building
Northampton,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:-,•;1 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 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 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 requ�esfih ex m n)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location 81 R7 R-9
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L)EPARTMEN'T OI' EUILDDJ G INSPECTION'S
212 Amin Street ' Municipal Building
2."'orthain-pton, Mass. 01060
Wo p,I{ER'S COMI TENSATION 1NSUItA.NCE A MAVl-T
1 - _ __ ----- - -
----------------- ---- (iictirs��'ff;mittc^)
:rite z principal place of business/ri:�;denc
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do hereby ccrdi}-, undt-r the p ii1S "Uld pcn IiICS of pCf�Ui1', .11a"
I am -,in emptoyer prOYIdIng the 10110 •:iI t '•':OSr:CiaS COSI�pC115?UUI] GOVC:7: C iU' ?TI}`
eltlployces working tin dies job:
�S1r2S1G COrsm') (`CLC;�tiil_717CI) --- (� G'-r ]Cn Date)
( j I anz a sole proprietor, y'eneral C-gnu c`or Dr hon', `O T)CT (CirG}C one) and •tla"re hired
t.}ie contractors 11Sted belova ,• o 'E „ the v orkP-�S cmpeIl53uon ,,)]Cues:
CNI am c O{( Orl(I1CiGr) (1P.SUPIIC� CCII? ":i'j:PGI1C{ ?11SIl�r) .T�?'; . ..-0' D21C)
(Name of Counmor) — (7115] I1C^ COII DC;i`'�GIICt' �l i�11) (E`: ^i]oD. ID aie)
(Name of Contnmor) (In;• anc� Co �n;il'o1ic: Nunllr r) x , r io 1�atej
(Name of Contractor) — jnsu ancz Comr�IV!PoUcy Numb,:r)
(sIL,G1_•.d'�iti CY�al i7._rt t.°:.---.. :n..r...,,.c.._:'K:..a.,er. , ._.... eli.�:<::-_.._...•.)
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it Sole proprietoi fc?11 havu no 011C '.'.'Ur�,lii 101 i11e.
�iil 2 Il0?1]C O\�;?1C" ti�i:0'1?11I1� ill i!... ',�,. ., iii•;i'"af.
NOTE:I?Icsc be aw'a:c thst'.,`.:ilc
not atete t1Ln throo units in a oe':,t :: ,z^•1r cr si ihcr o a c ex<bcvtall}'o: :::>-r, h
c�:ployc3 uzr�cr the tvc:I:�_cc:;.�._.i-n i c (C;T '2 c 1(5)),z,:;:r..'icn'vy s hn:nmuacr:`cr a Gccu c<r=f:n!::r.c:
legal etawz of an cz=ployer under L o Wori;c.'s Con,,;,ion!-cL
I uadcrstxnd thxt a cmy of ibis ctxtc:a c:xy bo fawnrd d to to iY.t a t of Irar_,:rul Aaidartf Of,c of for tlx
covvxgc vgifiarl;oa and tlLt L-ilurc to c-� o�cr g.urn:sc:.iM 25A of MC-1.152 r_ta IC--d to tbo imposition c`c ir�1 pct nl::a
cvmuting of a fur_of up to 11-500.00 hn�i'nr of up to cn-}-c:r.r.-1 civil perultia in�.c fcnzn of:.S!c'`,YC-ri Ord t:--d
f r of S I oO.QtJ x dsy x�,%irmt m-
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For dct;xrtt2yatxl u.e crrl)'
Pcrrnit Nu111b' r
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Sinaturc cif
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.ices: JI'crnriucc. ___ t-
51=CT ON B GON ION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
R-e . _e e- -o;; rn z ve -'en�.' ract �,. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECT O WORKERS' COMPENS 711ON 1NS}URANCE 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"homeo,,vner" 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 fo-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 L sand State of Massachusetts General Laws Annotated.
Homeowner Signature r _
I ,
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r
OF�ROPOSED�1i1 R check a
I �
,A
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ a ig Siding[ ] Other
Brief Description of Proposed Work: tp►�t4k.XTtuN aP 264.c 'LaWr- - F,4M+C4--- lAt L�ISirNC fum An-CA
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0• Sheet 0
6a, _ .:ear o ��t onto existing#ing ompe e he "Iow ng
a. Use of building: One Family ✓ Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms Z
c. Is there a garage attached? N�
d. Proposed Square footage of new construction. e' Dimensions
e. Number of stories? Z
f. Method of heating? 4,✓i-� GAS 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 No. Is construction within 100 yr. floodplain Yes Nc
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
� U.,IjUORIZATION TO BE COMPLETED WHEN "
OW S
APPLIES FO R BUILDIG PERMIT
I' as Owner of the subject property
hereby authorize to ac; or
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.
S3— Hc, i4--
Print Name l
/J1 16.5
Signature of Owner gent Date
Section 4.
ALL INFORMATION MIDST 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
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T 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 th,e site contain a brook, body of water or wetlands? NO DON'T 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
ing Department
E Main Street
D oom 100
AUG -h% 200 N pton, MA 01060
phone 13 7 1240 Fax 413-58 7-1272
A IROWAIINKINI AD906 iJr, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1!- SITE INFORMATION
,� _tA� 'phis sec f�."M � � � by fificF �"• <;
1.1 Property Address:
EImSt District: ricf
SECTION.2- PROPERT,Y>OWNERSHIP/AUTHORIZED'AGENT
2.1 Owner of Record:
Sr �G1 �Cva 6.,,E !- A`^'L-O/ 1 RYAojAr /1-04 �=y a-�%c -z—
Name(Print) Current Mailing Address:
b'g6 C7.1 L--° ✓ Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SEC' ESTIMATED'CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use°Only
completed by ermit applicant
1. Building (a) Building Permit'Fee
2. Ele"rical (b) Fstimated Total Cost of
Construction.from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) 3 Check Number
gig-
This Section For Official Use Onl
Building Permit Number: 6 "1 Date Issued:
Signature:
Building Commissioner l.nspector of Buildings Date
t
I � BP-2004-0135
GIS#: COMMONWEALTH OF MASSACHUSETTS
t
u ` ' CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0135
Project# JS-2004-0211
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 35719.20 Owner: HAWLEY STEPHEN&J EVELENE HUGUENIN
Zoning:URA/WSP Applicant: HAWLEY STEPHEN &3 EVELENE HUGUENIN
AT. 81 RYAN RD
Applicant Address: Phone: Insurance:
81 RYAN RD (413) 582-6868 ()
FLORENCEMA01062 ISSUED ON:817103 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL WOODSTOVE
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• Receipt No: Date Paid: Check No: Amount:
Building 8/7/03 0:00:00 3818 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
81 RYAN RD BP-2004-0135
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:22D-006 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Cateeorv: BUILDING PERMIT
Permit# BP-2004-0135
Project# JS-2004-0211
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 35719.20 Owner: HAWLEY STEPHEN&J EVELENE HUGUENIN
Zoning:iJRA,, SP rAg1j.17-ctin Wkl.,^�-I'Y STEPHEN & J FVEI,ENF HL 15,I)E IN
AT: 81 RYAN RD
Applicant Address: Phone: Insurance:
81 RYAN RD (413) 582-6868 O
FLORENCEMA01062 ISSUED ON.817103 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE
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 REGULATION
J
Certificate of Occu an Si nature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 8/7/03 0:00:00 3818 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo