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DEPARTMENT OF BUILDING INSPECTIONS
�l
INSPECTOR
212 Main Street * Municipal Building
Northampton, MA 01060
,Vol
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 1083.4 to
act as 11.js/her 11.;s/her construction sul� :=:or. T he statC deflines "lloineowIler" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or ttivo family
dtivelling, 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,
to,[ r t 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 �� U
Address of work ��'� �✓-t`�� �� ,(
location �l
8 6 �lrasexchnectts' —
`� 1-\ —
DEPARTMENT OF BUILD11\C INSPECTIONS �}
212 Main Street ' Municipal Bull(ling
Northampton, Mass. 01060
'NORICTR'S COMTENSATION INSURANCE AFFIDAVIT
(1ic�rs°cilcrmittcc)
with a principal place of business/residence at:
(strc.-t/city1s'tatc�r�p)
do hereby certisy, un(ier the pains and penalties or penury, that.
O I am an ernployei providing the following .vorker s compensation coverage or III),
eruployees working on this job:
�st>rash Coral'ny) -- --- (Polio;Number) ---- -(E-xTir rion Date)
O I ani a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below %,-ho have the follovilling workers compensation policies:
(Name of Contractor) (Insurance Companl,Poticf Number) (Expirnsoa Date)
(Name of Contractor) (Insur-ance Comca;yfPoticy Number) (Expiraio❑Date)
(Name of Contractor) JRSUFUIC: COMT-'mylPolicy Number) Date)
-- --------------
(Name of Contractor) (IOSZII!IlCe Comt"I:!Y/Policy Number) (E>:ait:aion Date)
(attadt td�itimal c.'�ct if::cr<a,:-. ::� io-,!..:ic i.:l canu:i a:F:�tn inlay t; Il c._d:ado: )
i
( ) I lull it sole propnetor 2t1d have no one -.,'ork>J1� for me.
I 1111 a home OAVIIC? re' ! i ll]In� all the %vo!r: iilYSelf.
NOTE plc�sc be nw:r;C that'.tia ilc tx xa :rrs :�c;play r,z tD a,:..:r,:c_:�i cr
not axec th.n limo uniu iit tit ct t�e I .�v,jrrs ra:w ec at Lie Rrc:n.!i zpFuttcr,^t thccto c.•c o,:<Ec_rallV crc::c::TC:o b-
can,,loyc--3 of cr tar work-'--co.:_:etirn Ac:(GL152 sa 1(S)),uppli_.-ion by a hoatcoulrr for a Lon=cc P=,.;::n:r C,,:!`n e 1�._
ltgal etatuc of an omplo}•oc under tba WUk,a o npo nation�cL
I undcztnnd taut a copy of t}iv oaten;cat c:ay be fotwnrdod to tbo D(xi L xsif of Ir>dstatrial AO66 tf Ofii of!: L FDA for tam
coverage vcrificalioa and that Edurc to tcatrc covcr &o under sccuoa 25A o11,i4L 152 can Ict-d to tha imposition of---J pa alga
000suting of a fux of up to S 1.500.00 an-i'or nprixx tr 1 of up to on:}-,ar arA civil paultia in dx f,,t of n Step W-k on'--d a
fine o(S100.00 a dsy ig;Linst me
Fc,gg utdal uio only
Permit Number
:tzp;l Lot r
rh Sign�xturc of Li --— Ie-
ccnsc cr�ttcc ((
J •
SECTION'8 -,CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder --- --
License Number
Address Expiration Date
Signature Telephone
9 Rerste"red HomelmprovemenfContractors e.' Not Applicable El
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE;AFFIDAVIT(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...... ❑
&RU 1L
�,.. 5 l
if ,. ome ®wnergExemption
The current exemption for"homeowners" was extended to include Owner-occupied Dwellings of one(1) or two(2) fanniiies
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 fer which this pen-nit 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 as es responsibility for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Zonin aws and State of Massachusetts General Laws Annotated.
Homeowner Signatur
e
SECTION 5 'DESCRIPTION"OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s)l Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ) Decks [ ] Siding [ ] Other [ ]
' Vt - r
Brief Description of Proposed Work: �ti ? +;c rfc-Lu`�L S �1 �/ -
_
--- -
4
Alteration of existing bedroom Yes _+'� No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes _ No
Plans Attached Roll ❑ - Sheet U
6a..If New..4dff§ and;or`addition`to existing hou5in>7, complete the folloWih�:
a. Use of building : One Family ___ Two Fancily _ O.t-ISer _
b. Number of rooms in each family unitt�_' _- 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 Woodstoves Number of each
g. Energy Conservation Compliance. _—_ Mascheck Energ Compliance form attached?
h. Type of construction
i. Is construction within 100 ft. of wetlancs? Yes No. Is construction within 100 yr. floodplain _—Yes Nu
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 OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�vn
La W f�VACS L` zz� t�,Kt as Owner of the subject property
hereby authorize to ac; o1
my beha f, in all matters relative to work ar:thoriz�d by th',_, twilding permit applic tion.
Sig atur of Owner Date
�1
C�U•'� - ��.., __ _ _ 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.
----------
Print Name
i
Si n _----- -- -- Date
.
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
E=xisting Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage _
Setbacks Front
Side
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 a h Registry of Deeds?
NO DON'T KN YES
IF YES: enter Book age and/or Do--ument #
B. Does the site contain a brook, body of water or wetlands? NO -ON'T KNOW
YES
IF YES, has a permit been or n ed to be obtained from the Conservation ommission?
Needs to be obtained Obtained Date Issued:____
C. Do any signs exist on the pr/ad y? YES _ NO
IF YES, describe size, type location:
D. Are there any propose nges to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:___
----- -- - 4" e0a e tit se.n..lx £
f Northampton Sta uU oT;j-err
f� l5 Iii ng DepartmenturbC�t/D��ew
2 Main Street SewerlSepttc A atlatii .tyx ';
�I!; Boom 100 WaterlWell Ava 1 :, k .`
4 Jug No ian�pton, MA 01060 TwoSets bPStuctu al Pans. '
i phone 41.87-- 240 Fax 413-587 1212 Plot/Sit"e Plans
Other°Spectfy>
N TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Prcpgrty address:
�- "`� Map Lot Unit
Zone 42K. Overlay District
Elm St. District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�J�nir rPri ;) c+t M ihnAddress ,t
G.
i
2.2 Authorized Agent:
I
,
Address:
I
SECTION 3 - ESTIMATED CONSTRUCTION COSTS 'L -
Item Estimated Cost (Dollars) to be T — Official Use Only
completed by permit ar,pl c ant
E gilding ' 60 (a) Building Permit Fee -
or
timated Total Cost c'
onstruction from 6
3, f�iumbirg Building Permit Fee
- ---------- -- ---- - -- -- -
(HVAC)
�.
Fire Protection
b oral =(1 + 2 +- 3 + 4 + 5) i — _ _ — Check Number
This Section For Official Use Only
Building Permit Number: �� Date Issued: -- -----
Signature:
Building Commissioner/Inspector of Buildings
File#4-2004-0051
APPLICANT/CONTACT PERSON TAKKI LAWRENCE
ADDRESS/PHONE 550 BRIDGE RD (413)586-6677 Q
PROPERTY LOCATION 550 BRIDGE RD
MAP 17D PARCEL 005 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REPLACE SHOWER SINK TUB TOILET&FLOOR
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 FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INI ATION 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 Building Offic 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.
BP-2004-0051
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0051
Project# JS-2004-0087
Est.Cost: $5000.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 35065.80 Owner: TAM LAWRENCE
Zoning:RR Applicant: TAKKI LAWRENCE
AT: 550 BRIDGE RD
Applicant Address: Phone: Insurance:
550 BRIDGE RD (413) 586-6677 O
FLORENCEMA01062 ISSUED ON.7117103 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE SHOWER,SINK,TUB, TOILET & FLOOR
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 7/17/03 0:00:00 3644 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo