17C-246 (5) 1040
WINDOW WORLD
5.
S6 DiMoCk
1" R
/*
Vo I Is,
If I
d
flow Tv
he
ty
�V,r
��►iAM p�,
Gity of Xorthamptan r
�117[S3ACt�lISC�f! -
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '>a
Northampton, 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: ,•isor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fami '
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)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Daze
Address of work
location
r
p�O f,.
} y Crif� af ; I _
a +r Rrtl ial]1I)tolt
qI.satcrhnar[ta' _
DEPARTIVENrT OP BUILDfIIC 1NSP2cTIOIJS
212 ;Main Street Municipal Building
Northampton, ATass. OIOGO
WOTUC:R'S COiY PENSATIO.N MSURANCF- A17FMAVI
i c--
j (]i�ns�Jperm�lice)
WiLh a pn,-?cipal place of businessfresidencc at: --- ----
TL
s - /Yfg- c IO-c_ (phone')
(SL7�.(/Ci t y/S1:diGIZ]P)
do hereby certify, under thc.patns and penalties of pc ' , :hat
i
( ) I am an employer providing die following!worker's coinocnsado, covemse for 111)
etnpiovecs «vorUng on this job:
(Insure=Conr ) (Pete:N,U- ixr) ---
i
( ) I am a sole proprietor, general coou-acor or homeowner (c tie one) and lave hired
the coon-actors listed below wbo have the folio,,wing worker's comoen-saiion pc!icies:
(1;am,- 01 Contrnc-'or) (I
nSt!rail t;:. Corneae y/i'ouc; ?"'um`<:) (r�:�,raccn Datc)
(Name of Counj0r) (Ln-7w-acz Como_anw?oUm, \umcsr) (Ex-Dir lion Date)
I _
i
(Name of Coaa-aao,-) (I-nsuran= Comp.anyfpolio}- N;unbu) (Espirrios Date)
(Name of Coaazcior) (Lasuran(z Comcauy/Policy Numbcr) (Expiraon Darr).
(anal �onJ x�cct.ilnc�-si_-�-to c�cuc�iaform,.=ion Pctaiaius to _U Coos-_=.G:j)
I am a sole proprietor and have no one wori ng for me.
( ,a home owner erforruina all thew r-
p 0 1. myself.
NOTE:Plesc be warc tfi,•wt-le bD=OC txrn wbo emPt°y P�cO=co do rcpaz work on r d-. L F,of
trot most sh n tfso L�fJ is--bcb the bom�read-or oo the P-o1o6��,:.= ox Va-artty ocrrd-td to Lc
eitployc�ttafe the- -kr'ec=P�oa A=(GU452,n 1(5)�=ppticaEon b-f a bomco-=fv c Ge=.or Penan e=7 evidco=the
IcgsJ naa>c of ea exployx under dto W.-Ik-la ComPoC3,�ion Ad_
i
i
[—dcsi.and tbst-copy or Chi.m.t.-mcm may be f«-,..a,d.d w the papa�of In�azJW AcaiAc Off oe oC lr-unt>a+rot the
Covof vc'if c=ioo,md that L-iltac to saatrt tovorase tmdc r soctioa 23A of?-IGL 151 can led to the ia90i'dirrw of aiminA Pca Wk
000vxiug of a tint of t�to S 1300.00 attdlor mt{azyt oC up W ooc yctr a nd aril pcaaltin w Cc form oCa Stop Wort;Ord=and.
fits or S 100.00.d_y'Pia-'a me
i
- .. For dcgartm=.-a1 u,c onJ7 - ,. .
Permit NuIDbcr
Lot
j S,Bnat f LtansaJPcrmittcc e
/ l
S
SECTION;8-CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of license Holder:
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
AZ<40 CA-/ 4,f J o C--L to *00 0
Company Name Registration—Num er -----
�.!a6 41 A4 rx—k- sr ?-1to,1a 6
Address Expiraftion Crate
A duo S �� Telephone
SECTION 10-WORKERS'COMPENSATION`INSURANCE:AFFIDAVIT(WGI.c.152,,9256(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 1083.5.1.
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 buildine 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
r
i
i..
SECTION 5-DESCRIPTION!OF PROPOSED WORK(check alt applicable)
New House ❑ Addition ❑ ReplacementtWjndows Alterations) Q Roofing El
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[1--3] Other[E7
Brief Description of Proposed r— �/ U
Work: -� � f r+C c V &y L Lnd L4 cs� 0 1 c�_. Co
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa 1 Ne oiase n ra di is #sO 4 iaas�t�g ;corx�plete tfae olfQi 1<V9
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
L 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 Ta-OWNERAUTHORIZATION-TO,;BE COMPLETED WHEN
OWNERS AGENT,OR CONTRACTOR APPLIES-FOR-BUILDtNd.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
I �� as Owne m thorized
gen ereby declare that the statements and information on the foregoing application are true and accurate,to the best of y edge
an elief.
Signed under the pains and penalties of perjury.
Print Name
Signal id a wne Agen Da
'
_
Section 4. ZONING All Informat-j6h 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
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume,&Location)
'
A. Has a Special Perm iL/Vuhance/Findi ever been issued for/on the site?
'
NO 0 DON7KNOV 0 YES 0 �
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO �_��
� uuN / K""= 0 .^^
IF YES: enter Book Page and/or Document#
��
B. Does the site contain u brook, body of water orwetlands? NO v���� DON7KNOVU ��. YES �~��
�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
-
Needs tmbeobtained x�� 0�tm�me� t~� �ate |ssued'
�_» �_� . .
C. Do any signs exist onthe property?� YES «�� NO �~��
�
IF YES, describe size, type and location:
D. Are there any proposed changes tonr additions of signs intended for the property? YES x�� NO 0
'
IF YES, describe size, type and location:
E. Will the construction activity disturb grading, or filling)over 1 acre ovisd part oyo common plan
that will disturb over 1 acre? YES K N r NO K 3
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
4
_
#y of Nortoampton
I j1ding Department
�12 Main Street `-
Room 100 `
orth mpton; MA 01060 '
.phT! ; 3-58 -1240 Fax 413-587-1272 r
'� :Fn�
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SIT z']NFORMATION
1.1 Property Address: This section to be Ompletedby office
m f� ,A J
Zone kOY@Clay DIStCIC
District sr . CB Qts#ncf
SECTION 2-:PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
✓Y) kJ L x.14 rid-
81 IV yyl l9 rt.J
Name Tint) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
j 0-
Name(Print) Current Mailing Address:
ure Telephone
SECTION 3-ESTIMATEDtONSTRUCTION COSTS'-
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ;(a)Building'Permit Fee
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) /j 6 Check Number /
This`Section For Official Use'Onl
Building Permit.Number Date:
Issued:
Signature: r
i
Building Commissioner/Inspector of Buildings Date
81 NORTH MAIN ST' BP-2005-1282
GIS#: COMMONWEALTH OF MASSACHUSETTS
MaR:Block: 17C-246 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Categ_oa: BUILDING PERMIT
Permit# BP-2005-1282
Project# JS-2005-1711
Est.Cost: $2156.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group. John Corbett 104000
Lot Size(sq.ft.): 20560.32 Owner: HAIRSTON ANDREA&PAN WELLAND
zoning.URB Applicant: John Corbett
AT. 81 NORTH MAIN ST
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON.6121105 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 6/21/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo