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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060
i
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction sups: ., 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 owider/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date J� O 4
Address of work
location
J-f 1>�O
B6 !it assxcilctstlls'
I
z �� L>FiPfit2ThtEArr OP BUILDING INSPECTIONS
212 Main Street ' Municipal Building j
Northampton, Mass. 01060
WOPJCER'S COMTENI SATIONI INSURANCE AYFIDAV1.T
v,,ith a principal place of busiresslresicenc
CIO he'l-c" CCr—LlI), L1l1Clcr di1 " pales anc pcn i1lcs 0i perJ111�1,
1 2111 aR CIIlp10)'el- providing th icllo"viru v'orr_crL5 coI'npcllSdllOD COVCSf:'1-',c '101 MY
employces worldrig on t11is job:
(Lusr ca Compam`) — (;ei;c;NtL l; r)
( j I a>j1 a sole proonctor, genPrLI c me cr c hon'cO;yve: (Cl cle one) and' gave iurcd
th. contractOCS hstP,d beio ,v o it the i0i� OrC:PrS CO _I)tn_i 01 1
(Na-me of ConL—actor) (TnSL IIG l CII'1^':ir'it G!]Cj Nlunt r) r:;i0i: �21C)
(NaLT1e of Contr<.c.o-) (71lsirince Coy z.`vPa!ic N='bcr; (F :o ..:ink Date)
(Name of Coatr2clor) (ins slcc l,0 `,3 'i%t�Q!IC:Nll.t111f r) '.X.:i i:C Dalc)
(Name of Con;nclor) Numb—z) (E::ri-::io Da(e)
i
( 1 <Lrl r'. :;Ole r)1Ol?r1CLS?i t`.i1Q it l'.; IlO 011 U l:iil l0L
18iI1 a lhomc CWI:C: i)Ci?d `li?lI?` Ill i?. 'v.,
m cr:c,;ait cl!i
not uK<c th--n thrcc uni+'s in r=:',Zz u a:
cIployc-3 u-ndr_r the tvc:?tci:ar -�:_i c/• (GL.152� ;(Sl?.r-+; ._:;ic::by a honlco" rs for c Lccu it F-z t'i;
Icgxl status of cn c�lo}'a under tt!n Wo:Lcrs t.oti,xr_-itioa!.ct.
I undcztz d thi!a copy of a"czatc:s•ruy bo fax,vctod to tip fY.sxirtzxs:!of Indz -ric!A,,:id�if Oil-,cv of i::a.vxa.a for tt:o
coverage vcrif=ioc cad that fulurc to s'ti:.uc coy`r_g uz scam_?5 A of?;CL.152 can imd to the itilposition c;a mir_1 prsl:a
oomuzuzg of a fur of up to S I SLO.LuJ a^�'v i^:fir vr,zti:1 of::�to cr.:}- r.-.i rvil crultia in do fcx n cf n
Lr�of 5100.00 a day trs.int!m:.
._ /) Fcx'dct%a.tvtrc[s1 u.c cnty i -.
S•";naturc
SECTION 8 CONSTRUCTION SERVICES'
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
pp
Not Applicable ❑
;�=Fteg ste�re �t`ome'1'lrttaro�ernenY�Contra'ctor r„�n�., ,,�, � ; ���,��,.y _m �
Company Name Registration Number
Address Expiration Date
Telephone
SECTIONIO WORKERS' COMPENSATION INSURANCE;AFFIDAVIT(M 01. 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...... ❑
41 ame ® 0111eM.ems Sian
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 them
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's
SECT W
IOt5DEPTiONOF PROPOSED ORK(check all app"lica�ile
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ) Other [ ]
Brief Description of Proposed Work: J7'K IA' o c;P,Pha N 4}rF S�N D �'F�/rfc'� j.�.���✓ ���y�a
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll O• Sheet 0
6a IfiT7:ew d"o"use nd,r:d"tl"itionto.existing housin' coriplethefollowrn
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 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
SECTJON7a {31AINERAUTHORIZATION TO BE, COMPLETED WHEN
OWNERSAGENTOR CONTRACTOR APPLIES FOR BUILD PERMIT
M.
I' 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 p
I' 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.
PO4 ViD J7 M'.eA'S-0Ai
Print Name [�
Signature OrOwner/Agent � Date 8 d Sl
P
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 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 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 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
212 Main Streetw
Room 100 a"
Northampton, MA 01060 _
phone 413-587-1240 Fax 413-587-1272f
APPLICATION TO CONSTRUCT,ALTER,REPAtR,*E116VI t6l6E6011.,'SH A ONE OR TWO FAMILY DWELLING
APR 3
SECTION 1-SITE INFORMATION
r' This se on to be completed by office
1.1 Property Address: §¢ 6s F* g
n
f f�or?�Nc° �rI — - Ma '' Lat � � lJn t
k
}
Zone" O�rerlay,1Qtstnct
dm S't.District =",° CB EAsla�ct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED'AGENT
2.1 Owner of Record:
PA-� Rle#rr c fa X) 3a C<iCy sf F�v,P,�.�rr /71Y. by06 c
Name(Print) Current Mailing Address:
Q ^a�.c.L— Telephone
Signature V V 5�
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature 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
,7 �G�• f
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 Q
q This Section For Official Use Only
Building Permit Number:APO 2/-! 7 J� Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-0975
APPLICANT/CONTACT PERSON HICKSON DAVID J&DARLENE J
ADDRESS/PHONE 32 LILLY ST FLORENCE (413) 586-3435 Q
PROPERTY LOCATION 32 LILLY ST
MAP 17C PARCEL 285 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildinp,Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 5 X 12 ROOF OVERHANG OFF SHED&INSTALL REPLACEMENT
WINDOW
New Construction
Non Structural interior renovations
Addition to Existing
Accessory 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 Stree ommission
-e av
Signature of Building 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.
32 LILLY ST BP-2004-0975
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-285 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildbg DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category. BUILDING PERMIT
Permit# BP-2004-0975
Project# JS-2004-1450
Est. Cost: $300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 9234.72 Owner: HICKSON DAVID J&DARLENE J
Zoning:URB Applicant: HICKSON DAVID J & DARLENE J
AT. 32 LILLY ST
Applicant Address: Phone: Insurance:
32 LILLY ST (413) 586-3435 ()
FLORENCEMA01062 ISSUED ON:4122104 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 5 X 12 ROOF OVERHANG OFF SHED
& INSTALL REPLACEMENT WINDOW
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• Receipt No: Date Paid: Check No: Amount:
Building 4/22/04 0:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo