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` DEPARTMENT OF BUIL.DIIN INSPECTIONS /=
INSPECTOR '212 Main Street • Mdoicipd Building
V S
Northampton, MIA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowne the right under 78OCMM 108.3.4 to
act as hds/her construction sup{v:,"isor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intgnds to be,a dne or twoPmi _-
dwelling, attached or detached structures accessory, to such use and/or farm structures. A
person who constructs more than one home in a twj o-year period shall not be considered a
home owner."
The building department for the City oNorthampton wants any person(s-)-who-seek-to
use the home owner exemption, to act as their owi construction supervisor, to be aware
that by doing so you become responsible for conjtpliance with state building codes
and fegulations. The inspection process requires that the building department be called
to inspect work at various stages, which include f undation/footings (before backfillh
sonotube holes(before pour) a rough building!i�nspection (before work is
concealed). insulation inspection if required) a' d a final buildin_z inspection. The
building department requires these inspections be ore the work is concealed,failure to
secure these inspections can result in failure to bbtain 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 issuo'd,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 a'Is the proper permits and inspections are
made r
If 1,-t'aj1tt kovLr understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspectiions necessary for the building permit
issued-to me
Date ®6
Address of work
location 5r
0/0 V p
1.
-
E (riff laf �\Tc7rfljalltptoil
R ' E 61xn.achnrcIfo•
w DEPARTMEATT OF BUIL.DTI�,'G INSPPCTIO1,5 -
j 212 Main Street Municipal Building
I Northampton, N4ass. 01060
WGI CCR'S COIYTE ISA'nO.N MSURANCF
6f
(1i ccnsxJpermi ttcc)
% nth a principal place of businessfresidence at: ---
'1 -
4.6Q (phone-')
do hereby cerdi -, under thc.pailLs and penalties of pc 'ury-, _h.i
(Gfi I :m an employer providing the follo%ving!woriccr's comocnsaoon coverage for Im
emplovccs worlong on this job:
U
(Polio:?:u r) — (=:-pirz or. D2=)
I am a sole proprietor, general cona-accor or homeowner (ci cie one) and have hired
the Conn-actors lined below wbo hive the `olloIV' P- worker's compen_szaon poiicies:
i
i
(i+ 1IIC Oi CO�t`CiO') �1n ranter- Cornoanypt ouci ""fumbc—) �Y'-J1.J Qn O11c)
I
('Nzmc of Cont vaor) (Ins-w ancc Comoaa}•iPOUM, \unc_r) (Ex-Dirtion Date)
j (N.me 01 condor) Onsurmcz Com
pan}1Po;c}• N:tsar) (Expiraen Date)
i
(NzMc of Contractor) (Lasuran(m Comp (Expiration Da1L).
--
(aII.aG� aocil zt'ca,if occ� _-ti•to incrtt�iafVr=,.30o pctu iaias to aU ocx•�-to:Z) .
i
O I am-a sole proprietor and have no one woridng for me.
II
I am,a home owner performing aU the work myself.
NOTE:plc=be cw arc rti* 1:jlc 6omco+acrd wtw ctzytaY D=oai cn c,ao c rgau w0f, oa i d.•<rt:^z of
not c3oct 0— the bomoo� mmdo cc oe the p-ouw i" s we L-= i We- l a lob
-avlor— the..u•k--; Aa(GU152-=1(5)�a.pplin6on by a bomeo—,,=fc a 6c�--a pe-mit rLy a rdmec tt;e
Ic-g.!—of as—Ployec O dR tlto Wottcolc com�omatipn Act-
.- 1 t+ad the a Dopy of chi.==.-moat—y be f«�.evd.nd to the p.egvtm�of 1n.diJ needmL�'OM—oC I+>rur+voe Jr-th.
tout asc"c'it•ctioc and that fllta-c to x.==fovtra,&�trodc-x OQ 21 A of MOL 152 caa I=d to the i^rpO On of cimiail P=-W=
eo¢v.:ag
or.fiat ort p to sSoo.00:rwcc• or up to oa y-,l rid cvu pcaafue is be form of a Stap Work Ord-and.
r»�o(S 100.00 t d_y ��J {/
/ ` 7 F,&,,----IJ--00er 27 N—----
s
Permit Numb ---- —
�t ° a
Siva t of Li scJP rtnitl� ce I rf
e
SECTION 8-CONSTRUCTION SERVICES .r'•
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature • Telephone
I
n� I-IS-1"7
Not Applicable ❑
91'-R fered fm ra�r�rerer► coo
I
Company Name
Registration Num er --———
Address Expiration Date
SECTION 10-WORKERS'COMPENSATION INSURANCE:AFFIDAWfT(NF L.c- ,52,.§25C(ri))
Workers Compensation Insurance affidavit must be completed and submittgd with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... $Q No...... ❑
QIk1�� II411 k
0 111-
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 wlf io 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 landon 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- ear period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a fo acceptable to the Building Official that he/she shall be
responsible for all such work performed under the building iermit.
As acting Construction Supervisor your presence on the fob sitje 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 Massachus4tts 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 responsibijity for compliance with the State Building Code,City of
Northampton Ordinances,S and Local Zoning and e of Massachusetts General Laws Annotated.
Homeowner Signature / Cu
t
i
I
t••
SECTION 5-DESCRIPTION OF PROPOSED W.ORK(check:all•applicable)
New House ❑ Addition Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[
Brief Description of Proposed e 'MA50 : ��cdlc-Q -l- /�lo0tt�'.1 Gl{lMN67
Alteration of existing bedroom Yes J_No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes �_No
Plans Attached Roll -Sheet
6a Ef lV�tnt rouse ft A nac c U toLX %eac�s#ii c Eio> st aK arl b eYe r irtlatrt� g:
a. '-'Gc of bui!ding•One Family Two Fnmily 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
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 conform to the Building and Zoning regulations? Yes No.
I. Septic Tank C!ty Sewer Private well City water Supply
SECTION Ta-OWNER AUTHORIZAT ION,-TOBE.COMPLErED'WHEN
OWNERS AGENT OR'-CONTRACTORAPPLIES:I=QRBUILDING PERMIT
1, + 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. r
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the y knowledge
and belief.
Signed under the pains and enalties of erjury. '
Print Name
r CZ
Signature of Owner/Agent Date
w �
^
Section 4. ZONING All Informad6h Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing PrDposed 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 I----------
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Variance/Fi nding ever been issued for/on the site?
No 0 DON'T KNOW YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Depds?
NO 0 DON'T KNOW YES 0
'
IF YES: enter Book Pag,� and/or Document#
B. Does the site contain a brook body of
`
Needs 000mobtained uora/neu Date Issued:
C. E8 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES
IF YES, describe size, type and location:
E. Will the grading is8 part cfa common plan
that will disturb over 1acre? YES K ) NO �J
~~� / ��,
/F YES,then a Northampton Storm Water Management Pa from the DPW iurequired.
|
it of Northampton
4Stat rPecm :
'ilding DepartmentaP�
2 Main Street ere fit,
Room 1,00 r� eluar��►�"` �
.4
Noc;thampton; MA 01060 0— 1cia ?arr t
phone 41:,h587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION t-SITE INFORMATION
'> This sectiorrao be completed b�affiCe
1.1 Prooetrt� Address: R O
Tocie 3 u
O ` t cerlauDEStc�'I �ao2 fr7tt 40
EI[mSt Distrrct CB DistncY
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: Q
rt cLw� 90 r
Name( dnt) J Current Mailing A 10/`
A Telephone
Signature 5 G Z
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION3-ESTIMATED CONSTRUCTION COSTS
Item • Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
J 1. Building •'' (a)Building Permit Fee 00
M%N
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 For Official`Use Only
Date
Building Permit Number.` Issued:
Signature: !'
Building Commissioner/Inspector of Buildings- Date
RE A It, o F d L.S E)
ti at rEE.N F/La m 7T tz--t<,—G-T' HO L'6
File#BP-2006-1191
APPLICANT/CONTACT PERSON ROTHER BRYANT P
ADDRESS/PHONE 159 ELM ST NORTHAMPTON (413)586-1424 Q
PROPERTY LOCATION 159 ELM ST
MAP 31B PARCEL 162 001 ZONE URB HD
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: REBUILD&MODIFY CHIMNEY
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 Street Commission
Signature of Bu4dingg: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.
r BP-2006-1191
G1S#: COMMONWEALTH OF MASSACHUSETTS
a
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-1191
Project# JS-2006-1761
Est. Cost: $3570.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 44431.20 Owner: ROTHER BRYANT P
zoning:URB HD Applicant: ROTHER BRYANT P
AT. 159 ELM ST
Applicant Address: Phone: Insurance:
159 ELM ST (413) 586-1424 ()
NORTHAMPTONMA01060 ISSUED ON:511212006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REBUILD & MODIFY CHIMNEY
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 5/12/2006 0:00:00 $50.003481
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo