31B-022 (4) ��t1AMpl, `
goo f_Crz#1y of Warthamptan Z
�I 85DAClt1[Sttt4
DEPARTMENT OF BUILDWIG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060 5`
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,r,• Sor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a one or tW6 fanu
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 eegulations. 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.
Date
Address of work
location
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I
(riff Of �\Tarfl}aII1 1011
� A � f ��a3sitc1lncttta' _
a DEPARTMENT OP BUIL Dr)\C INSPECTION'S
212 Main Strcct Municipal Building
Northampton, Mass. 01060
WOR1Q:R'S COIIvQ';✓NSA'ITO.N MSURA.NCE Al FMAVI-1-
1A
(li ccusxJpermi ctcc)
\,.,ith a principal place of businessfresidence at: -----
(srJ�t/cirJ/siaiclap) -7 �C�j c;
do hereby certify, under the puns 2nd penalties of pe>7ury, hat
( ) I am an employer providing the followine',-vorkcr> s comocnsa:ion cove zge for in)
etvplovccs working on diis job:
I
ansu an=Cociran) (Policy Nu--ab-cr) -- (7=:pir-,00r, Da--)
( ) I am a sole proprietor, general contractor or homeowner (ci cie one) and hrve hired
the conisa(nprs listed below vqho have the follotvinQ worker's policies:
j
i
I
(l+t1rl2: Oi Co:'.0^cior) (InR!r3ncc COIr1D.Ln)-thole !,Zu 1*<:) -- �_i:>iFJ:?Qi!D.ItC)
(Name of Contrcior) (Insrrancz Comoanv/room, Nuncrr) (LXDir ilon Date)
(Name of Connaao,-) (In ur-ne Compan3•/poOc)• 'NuMbcJl (Expiraoo Dacc)
j (N2-me of Coutaetor) ( uran Comp rE� iaooa Dat,
)au /PoUc Numbu) .
j (atxs.��di::•oeal exct,irneC.--,w ctcu43C iaronnaEoa pcztaining to.0«,,-to-
i
Y I am'a sole proprietor and bave no one workiog for me.
( ) I am..a home owner perfon=g all the work myself.
NOTE:pl=sc be coot tfi•• 1 ]e bocz o 'Dcrs�to ccaD1oY p—com to do - c=.,:cu o C tcpzII cork on t d..ctL^y of
apt mote then Lb roc t?,r in xvich ttx boa=-m<r r cmd=or oa the IIouz,6 zppurtcas=tbeen wt pot garlly oerd=ni to be
eeirplcr -r undc the 0=.* --*•oa Am(GUI 52ss 1(5)} :pplica6oa by a bommaaa fcr c lice_cc pencil a_y aid o-Lbc
IcPl ctaa,e of as—Ploys under d>o W.+k e.CompoonaLioa Ad
- [uMz=Tiaod a y ba foc--.ded to tbo peputmmd orin&arsiel Ace&-&oiL—or tm—Coe tb-
-V---6'c`C if tZtioa cad U--,L-d—to so--arty`co—age undo soaioa 23A of MOL 152 cta led to the i= i -of c imi— pcoiwl=
joomisiag iota ripe oCtrp to S I X00.00 and/or ix�eri or up to o«yur a ad aiil p=arse in zsc roan or Stop work order and a
rim of 5100.00 a d.y cry tY
For dcq.rtm�-�u.c ody
,1 PerMjt Number -- :
Lot�r
^'� '�-C./-..^+• ����-- 1t.
SIgnaUmc of Litzr>_scr/Pcm-iucc --fie
SECTION 8-CONSTRUCTION SER"ES, +'
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: - ns e Number
r
- License
Address Expiration bate
Signature Telephone
�ecx� ' u: x� ctvernen�o�#ra n ,
- Not Applicable ❑
Comoanv Name Registration Number
Address i' Expiration Dat
( L/cv/21 111/6 f L; L'Ll C)l6Z,G Telephone ,
SECTION 10-WORKERS'COMPENSATION INSURANCE AFEIDAI/1T(M G:L.c 152,,;§25C(Gj).
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...... ❑
lm:
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 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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1W �*
SECTION 5-,DESCRIPTION;-OF-PROPOSED WORK(check-allapplicable)
New House ❑ Addition E]11 Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[0] Other[ED]
Brief Description of Proposed / ,�,.4q
Work: `�IVG C C1 E iitr l �G1"?� Jn 6jL
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
x Y
65,1 Ie ai7satt° cti awls#incciol=s�.ita�+carib eta.#het olfitauging:
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 7a;-OWNER AUTHORIZATION TO"BE.COMPLETED WHEN
OWNERS AGENT-,; CONTRA'EJOR APPLIES fOR BUILDING.PERMIT
till
as Owner of the subject
property
hereby authorize W,C'
to act on my behalf,in AT relative o work authori*t�is building permit application.
s
Signature of bwner Date
as Owner/Authorized
Agen reby dedlare4hat the statements and information on the foregoing application are true and accurate,to the best of my knowledge
a6d belief.
Signed under the pains and penalties of perjury.
i
Print Name
,d
C L-2 Q�
Signature of Owne Agent Date
Section 4. ZONING All Informati6n 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 I 1 4
Frontage
Setbacks Front
Side. L:1 i R: i L.+� RE
Rear U
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 0 DONT KNOW 0 YES 0
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page; i and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 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 0 NO 0
IF YES, describe size, type and location: i
i
D. Are there any proposed changes to or additions of signs intended for the property? YES NO. 0
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 0 r NO 0
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Nortfaampton
Building Department
212 Main Street
Room 100x:
Northampton;"MA 01060 '.
phone 413-587-1240 Fax 413-587-1272 jil ii 11
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
77]SECTION.11:1-SITE INFORMATION
w � Thts sectrort to be cQtnp eteifbynif`ice
1.1 Property Address: u
�Z666." `1 " OIIB ADLS GIGts
/7�"E�/C....�
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED,AGENT
2.1 Owner of Record:
I
CDda'me(Print) Current Mailing Address:
Telephone
9nt
2.2 Authorized Agerit:
p1971.s^24n0
Narne(Print) Current Mailing Address:
ry �j y 22s C)
\M
s re Telephone
SECTION 3.-ESTIMATED`CONSTRUCTION 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) Check Number
This Section Fot•Official'Use`Onl
Building-Permit-Number• Dsued:
Signature
i
Building: sion r&7 tor of Building's Date
20 ALDRICH ST BP-2005-0945
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Bloek:31B-022 CITY OF NORTHAMPTON
Lot:-001
Permit: Buiid[ng
Category_ BUILDING PERMIT
Permit# BP-2005-0945
Project# JS-2005-1315
Est.Cost:
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sq.ft.): 6229.08 Owner: CADETTE ANTHONY F&MARSHA E
Zoning:URC Applicant: DE Sheppard Roofing
AT: 20 ALDRICH ST
Applicant Address: Phone: Insurance:
224 BERKSHIRE TRAIL (413)587-00920
CUMMINGTONMA01026 ISSUED ON:416105 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE ROOF OVER I LAYER
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 Sienature:
FeeType: Date Paid: Amount:
Building 4/6/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo