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DEPARTMENT OF BUILDING INSPECTIONS /=
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INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060
>r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as l.is/her construction supe-,•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 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 roujzh building inspection (before work is
concealed) insulation inspection (if required) nd 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
ma
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.
f G4Date
Address of work
location -5
� �, (1,iftT cif �itt�-211�i1tt}�fatt � �.
,• 6 `i�[SSA(i)ItSCIl7
m DEPfu2TME-NT 01' BUILDING INSPECTIONS
222 Main Street ' Municipal Building
Northampton, ATnss. 01060
WORKER'S CONII'ENSATTON 1NSUTZANO A M)AVI-T
(liens°::'Crrtnittcsj
with a principal place of busi msdreidence ar
do herE:by cenHy, wOer Ac hauls and pCil itlC., nr pCtr�ul�r illflt_ -
I w A-employer providing the iollovany '.:ot-kcTI-s compensaLaoD GOVCI'a C i0r Iny
etuployees working on t}Iis job:
00m mna Com m') o-c;Number) ---- (ExTir,zi3n Date)
j I am a sole proprietor, 4?enerai con=cccr hor:eo. ner lcLrcle onei and lr�,'e hired
the conl actors listed beiow„1;0 1:2.-� tho `o!c , . j k e e _o :
ork rs co�_.� n�:on .tc.
(N=c of CO 1CI CtGr) (7Lr1fu,,cr; COI': `::i'i:IolIcy Mlintcr) x; muc' DaW)-
(Name of C�IlIr l0") (11�SJ: P.C^ CD:,L,_Iayfpol1C 1"71 M,t'^r) 'late)
(Name of Contramor) (Ins uice ComF;an;;�?o(sc: NuJntxr) IF i oa Date)
- (Na.me of Contm. ctcr) — (InsZ rand Cotilr v�'Polio Num;�r __. (E: _ qr
1, I i1IT1 <'. Ole llrol)I1C:Ji a..;l ila-vc tlo one .:Ord:?IP fbr me
I am a holnic C\'i?7'ti. ii .. ,`IiIIII a!l
NMI":please be n:.-arc[tart•.vL13e tx:co :r «,:o r..ap! ;r,.-_ n::>::_. _ cc ar.r_n m :-,a r «cl!:
not mete th_a three ur:it3 in ui`et:.he or a: ..:s ._r cr s1 ire o e n.t cc-vsally
c Ploy,=3 urv<' ter lvc:,ze_-ar x--:_:i^c A.c' (iLi S2.ic: 5ll.- r 1,-
( ( •.,:�`:^.:JCi::JV a hnta�ou-t>cr'or z L�u c, r :r.r `tr.c,--
legal rtatur of an aaxployx unur tLo Wor�cY'r t:oi,>m_-.ation AcL
I undc-st.ad thL a cmy of this date: -'.cuy ho f(x nrtlaJ to tln U'(xvtzxszr of Indi>,striJ Arcs& 1:�r'Ct acv of i:: w x fot t!x
cover-ttse vrr-i[ealioc tend that C_ilure to t-r re cortrn�urn: eC,ic^2SA of i.tGt.752 r_tn lc—d w the imposition c;c m-11 pall:c
cvcz;iztutg of IL ftrr_of up to S 1.S .CuJ a:s r ir.::lr;ry ;,of;;?to cr,:}- r.:.j evil xrultin in do tc nn c•f n Str. `;'c i,(}u s:1 n
firs oCSI00-00 a d_iy t .in:t tnc.
IOC artiZYZC11 u1 GIly
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SECTION 8 ,CONSTRUCTfON SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
F2e�gste�er� bme mnroveme`ht Con a;:t... a: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECT19N 10 WORKERS' COMPENSATION INSURANCE AFFIDX IT(M G:L. 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...... ❑
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 108.1.5.L
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 fer 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 ing Laws and State of Massachusetts General Laws Annotated.
,,
Homeowner Signatu J
SEGTIOf�S=DSf RCP�TFONOF RR'OPOSED 1NORK=lcheck�all aoalicabte)r U
aksf5nw+•o�:+�i�es4a:aasm^ +K ,? w•.x �. ms+:" x'.3 „n.°",w.+.
New House ❑ Addition 9L Replacement Windows Alteration(s) ❑ Roofing 9K .
Or Doors ❑
Accessory Bldg. ❑ Demolitions New Signs [ ] Decks [ ] Siding[ Other [ ]
rief Description of Proposed
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll D- Sheet D
6a 1-' = e�iu o: se nd o aadrti.on to ezistln =h u0 sinfr comp�b a tWNMJ:ow :
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? h/C
d. Proposed Square footage of new construction. C Dimensions S x
e. Number of stories?
f. Method of heating? /Xy t9212- Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Mascheck Energy Compliance form attached?
h. Type of construction W 0 7
i. Is construction within 100 ft. of wetlands? Yes u.-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 7OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERSpGENTORCONTRACTOR APPLIES FOR BUILDING PERMIT
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
I, ��� < ��C 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.
Mned de r the pains and penalties of perjury.
R
rtai,Name
Signature of Owner/Ag nt Date
r 6
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Section 4.
ALL INFORMATION MUST BE COMI LETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
I
Lot Size
Frontage
Setbacks Front
Side L: ��R: L:�R
Rear
Building Height /
Bldg.Square Footage �j �s % //7 ,S7
Open Space Footage V %
(Lot area minus bldg&paved �j C
parking) U J S
#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 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 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:
e
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060 w
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE Oki EN OL H;A ME OR.TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
f rs section to be tho ted by office
1.1 Property Address:
M =- � 1n
(� k Il►� 1�l C� '� Zone; Overlay taiistnct
SECTION"2-PROPERTY Y-OWNERSHIP[AUTHORIZED AGENT
2.1 Owner of Record:
17/0&0
Na ,Phi nt) Current ailing d e
A-— ��"-"` Telephone
Signature
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 �.e� (a) Building Permit Fee
i
2. Electrical / (b),Estimated_Total'Cost of
i c Construction from 6
3. Plumbing cats Building;Permit Fee
4. Mechanical (HVAC) v� Oe
5. Fire Protection
6. Total = (1 +2 + 3+4 + 5) / Cad ` Check Number
This Section For Official Use Only J/11f L t
Building Permit Number. .��0 7 '' 2— Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-0842
APPLICANT/CONTACT PERSON STRAMESE PAMELA
ADDRESS/PHONE 91 PROSPECT AVE- APT#1 NORTHAMPTON (413)584-6648 Q
PROPERTY LOCATION 38 LILLY ST
MAP 17C PARCEL 286 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERM_IT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: ADD 2ND FLR DORMER(FULL BATH) RENO 1 ST FLR BATH&KITCHEN
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
i FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
ATION PRESENTED:
THE
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 Pen-nit 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 fi-om CB Architecture Committee
Permit from Elm Street Co ion
— 100
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.
38 LILLY ST BP-2004-0842
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-286 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-0842
Project# IS-2004-1247
Est.Cost: $19000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 9670.32 Owner: STRAMESE PAMELA
Zoning:URB Applicant: STRAMESE PAMELA
AT. 38 LILLY ST
Applicant Address: Phone: Insurance:
91 PROSPECT AVE - APT#1 (413) 584-6648 0
NORTHAMPTON MAO 1060 ISSUED ON:315104 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD 2ND FLR DORMER (FULL BATH), RENO 1ST
FLR BATH & KITCHEN
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 3/5/04 0:00:00 1191 $60.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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38 LILLY ST BP-2004-0842
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-286 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-0842
Project# IS-2004-1247
Est. Cost: $19000.00
Fee: $60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 9670.32 Owner: STRAMESE PAMELA
Zoning. URB Applicant: STRAMESE PAMELA
AT: 38 LILLY ST
Applicant Address: Phone: . Insurance:
91 PROSPECT AVE - APT#1 (413) 584-6648 0
NORTHAMPTON MAO 1060 ISSUED ON:315104 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD 2ND FLR DORMER (FULL BATH), RENO 1ST
FLR BATH & KITCHEN
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: ` ough: G/��� House# Foundation:
Driveway Final:
Final: `,Ov Final: ��y/� �i _ O
Rough Frame: r ajj � /
Gas: a Fire Department Fireplace/Chimney: ,/ J�
Rough: 8 a( � (Z-7ii. ;:�st�s�tior�: C/'` 7�'�T t0�'4,
Final:'? .,.2,1..-010<Smoke: Final:0[< g ` 02 o-®y-1hq
THIS PERMIT MAY BE REVOKED BY THE CITY Of NORTHAMPTON UPON VIOLATION F
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 3/5/04 0:00:00 1191 $60.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo