18D-035 (8) Grit of Nart4aiuptart
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3 DEPARTMENT OF BUILDIT;G INSPECTIONS /
212 Main Street • Municipal Building
INSPECTOR
Northampton,MA 01060 .
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as 1-is/her construction supc:,,*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 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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^s m llEPfit2TMENT OF LUIL)oJ G INSPECTIONS
212 11Tain Street ' Municipal BulUng
2,,'orthampton, Mass. 01060
W0RTCE R'S COMTENSATION I
N, 'H AYM AVIT
(lice.s^Jrf;mittc^) -
%vlth a principal place of businessJr-criid c nc
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d0 hereby Cer-Lily, tlliClc1 L11C l)<:iilS aiid pC1131tiCS OI pC;rJllr�', i}lilt
am an employer providing the follov.,M,c '• orkcr`s colnncrlsation tor m),
emploVCes working on this job.
�j Gad T� U7`�f1�1 r.
aranc Compam') clic.?�'u nlxr) (F�=pirdon Datc
( ) I im a sole proprictor, genaral c-oi1'a-aCC0r cr nor ceoWoer (Ci cle one) and 't;a,-e tureci
the contractors listed beiovvr ; l:o the. folic . :g ryOrkers co,-o, -on .col
(ITIILIlC Of CnnISlCiGr) (�nS nCC COIP-^;:"i'i PG�1C{ TJ17121tYi) ?:i"ritiCi: DatC)-
(Name of Conti ctor) (Jmsurnc: Con?ra„N,/Pchct' N + 1 kr_r) ati(n Date)
()',lame of Contractor) — (1nS ?I1C^ (-Oi ;'?n;i/hO�h^ Ntt.7I?1i r) \-:T 3i:( Dat',.)
- (Nalne of COnt-3CI0r) —- (Iosumnc- Conn:-ay/Policy Numl;Lr) (} ::ri :tior' Date)
( ) 1 i1II1 a ;ole prOy)nc,"oi E1 11 havc no oil' v lint tot M".
I dill a homy
1':0'I1-1:plc_sc be awarc thsc.t i)c tfcr�a it .+:c rnp1.. ,i>:. ;.>.._�_1:usnc�cx:c_n Cam Cr ^:au a cl!in
not¢fete tlLn throo t:ni+'s in t ---'Cit he F,x .,aZr rc: in a;'` :;_s:r.ricr_r1 Slur o n2 n_t ce:rsill i c: ::::_:: :c b:
—1ployv-3 u. r Qx. (5)).a+:;i_.ic:;by a hotamt< acs`cr a Lccu ct pern:i:
legal rtatut of an amploye'r undo tho Wcvlrcra ocL;w ,lion!,cL
I tu>dctxt.and thi!a copy oI this ctatc::s_•ntay bo fo,— lo;l to v»[Y_ynrtxrry of 1r.dti>_striel Az6--13'Clucv of::_;+.�r�'o for tlx
coverage vrr-[Gcatioa turd that f_-Uur--to t�.rc got ut 3: cGiM 2 5 A of MG1.152 can is ti to the imr�siiia cf c i^_1 petal;:s
comistitta of a ftrr_of up to S 1-500-OJ of t;p to rr>:) e-.1 civil pcm1tin in d'c Irnn of a Sic,+';�'^-*i'.Oti=ar,:l a
fire-of S 100.00 e dsy again st m.. .
F,&i —111 e`!use D ily
vf.�.. Yc/rrnit NUMI) S -------1
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S C O I iiN IGWSERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
yl �J r��-- v�4 BSS,
Address Expiration Date
Signature Telephone
CJ)- �;,7—�Jo
e -s.e e : rn m. exnen n racto Not Applicable ❑
Company Name Registration Number
1964.0 1d016 Z��
Addres$ Expiration Date
-Te) )-44 Telephone s —,W� 0 4 g--L9,0
SEC�0fi3V0RKERS'COMPENSATION INSURANCE AFFIDAVIT,(M G.L..c. 152, § 25G(6))
Workers Compensation Insurance affidav)'t must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance 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 acecptable 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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SELliO, . F Tf117N 0 ROPOSED WORK& -fil., :lea I!ca�ble 'r
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i ice•:._ :.-°� .'-.�:.. > ,..:'._..','�,°a�.:,��`�..,�2r'•;` : fi..., „¢.�' 3'�`�, ?z- _ "�fia�, ��,�
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing' ❑
Or Doors ❑ r
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding[ Other [ )
Brief Description of Proposed Work: — f! 'Tr9 / ,; S 0,/
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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
a, M or a, drtion to exr5tin ah >o sing °omp` a fi`e Ali wing:
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. 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
S Ca ��Z�RIZATION TO BE COMPLETED WHEN
1= ONTRyACTOR gRPL1ES,FOR BUILDING PERI!IIT
max:
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as Owner of the subject property
hereby authorize to ac;. oi
my be alf, in all matters relative to work authorized by s Building permit application.
2
Signatur of Owner Date
!, f " Z" �� as -VAuthorized Agent
hereby declare that the statements and inform tion on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Z„C,4'0;
Print Name
Signature ofQ_ww/Agent Date
s.
Section 4.
ALL INFORMATION MUST 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 the 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
Building Department NOV 2 4 �
212 Main Street
Room 100 —
Northampton, MA 0100
n4
phone 413.587.1240 Fax--41-3'.587-1272
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APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
1.1 Property Address:
f
k"l A "TU
EIm.Strict< _
S°ECTfp! 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nam Print) Current Mailing Address:
C �� Telephone O
Signature =— '`�~ — � �+j a
2.2 Authorized Agent:
Name(Print)(Print) Current Mailing Ad ess:
l
Signature Telephone
SECT10N�3 ESTiIMATED CONSTRUCTION�COSTS
Item Estimated Cost(Dollars) to be Official lJse10nly
completed by ermit applicant
1. Building Q Cam. (a) Building Permit Fee
2. Ele c"rical .�— (b) _-stimated Total Cost of
Construction from 6
3. Plumbing ✓_. Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = 1 + 2 + 3 + 4 + 5 6 --
( ) �� � � --� Check Number
_This Section For Official Use Or l .
Building Permit Number: -. Date Issued;
Signature`
Building Commissioner/ ns p'e.ctor of Buildings,,,
Date
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48 DAMN RD BP-2004-0657
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 18D-035 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2004-0657
Project# IS-2004-0941
Est. Cost: $1250.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sa. ft.): 19994.04 Owner: KERRYMAN PARTNERSHIP
Zoning: GI Applicant: B & R Siding
AT. 48 DAMON RD
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586-4167 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON.1215103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VINYL SIDING
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 12/5/03 0:00:00 19038 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo