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...it,. ..„„ .*,-gd,--:-,...x. \ 71 _ \ � DEPARTMENT OF BUILDING INSPECTIONS _ ;:
INSPECTOR 212 Main Street • Municipal Building '� > a
Northampton, MA 01060 .
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris /her construction supi. Hsor. 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
4.
•
•
t. (yifr cf pQ_L"f1 •
• firs gi �� • DEPARTMENT OF BUILDING INSPECTIONS , -- 1
212 Main Street ' Municipal Building
Northampton, Mass. 01060 r'
WOP�14:R'S CON ENSA'X'ION - I,'�iSI CI; A YU)A \T1T
•
(I1 ccIISX/ permitt )
with a ptir-icipal place of business/residence at:
7-2/' � �� < /Mi ��l C� "� (
(scrr4/a ty /stale! n p )
do hereby certify, under the pains and penalties of perjury, hai
( ) I am an employer providing the followinn worker's comocnsadon coverage for my
employees worUng on this job.
(Lnsurinc Coop-Loy) (Policy Nu_-abcr) (E.: Dztz)
( ) I am a sole proprietor, general contractor or homeowner (cilcie one) and have hired
the cono actors Listed below who h2ve the following worker's co as adon policies:
(Namc of Cont:aczor) (In w—oncc Coinoan }i ?ouc; Nurnhcr) (1--`:J11'JLo bate)
(Name of Contractor) (1nsiranec Comoan', Po!ic Nunacer) (t t)u tion Data)
(Name of Coaaacto, - ) (Insuaaco Company/Policy N.>six_r) (Expiration Date)
(Name of Contractor) (LoSurancv Compat Numb -.r'1 (Expiration Date) .
(a ve r oczl rL.o if nctci.n to 'ex h.,& inform .a oo po to .11 ooafr-son )
(f am a sole proprietor and have no one wor''dng for me.
( ) I am a. home owner performing all the work rnyse f -
NOTE: pl�,c be [tIc: Wiz)c Ixmxrv.vora u cccrp lay pcwai up do cs • n '.:w00 c rcnv ..ocz oa , dS.-*I1 F. of
CO( mace th:.c ' oe ter.+ in which tbo boccow(nc raider o• oo the p-oun6 zapu.rtcv_rl tbc-mo ooe fir. --.lty oern:d- -cd to be
citployc
• - ttx wee-k.: o - -•. ;c Act (0L15 1(5)). apPliati by n bomnoavcr for c - cc pm-rah tn=y c.•n•-.ncc cbc
Icpt taa c of en cc:ployoc under dio Work-eel. C.ompoon.tion /,cc_
1 uadc
th..t . copy of tbi, mt®x: ca. y be f «-.ruled to ch. pcp..rtmcoi of 1.A Srid offioa of ( for tb,
covcrisc veil erica btd t ri L•i1tz-z o tmuc'covcragc uodc waion 25A of MOL 152 an Ie.d to the > *t*tioa of aimiall pco itio
Q iszzg of a floc of IT to S1_300.00 .ndlot isrprisoacocol o f up to con yv cad c wit pewY,ia o tx form of = Stop Wort Ordcs end
rub of S 100.00 , thy ,Fpinn toc..
For ima -'1 u,c only
/ i . ! � Pit ritlIIltyCS
Date )
1pazturc o Lic�urJPct-rniu - -
it
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �/ Not Applicable ❑
Name of License Holder • C GLi � 4 Z A j 6bf
/ License Number/
j f a< o -a/ 17,--; /;, ,d/7, ox) 6 _ / W�1 /
Address Expir tion Date
Signature / r Telephone
9. Registered' Home?Iinprovement Contractor 21- , _ ,•` Not Applicable ❑
C p Name Registration Number
l / 6T`, " G ,c (' /i_ / / L_'o;'CL L 'I C)( CC r / 17f '- C/ Z
Address / / Expiration ate
—
Telephone ' - �f.�,
>
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 LJ No ❑
11 . H o me y O w ri er. E
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. ofland 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 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
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House n Addition n Replacement Windows Alteration(s) 1 Roofing I I
Or Doors Cl
Accessory Bldg. ❑ Demolition [ 1 New Signs [0] Decks [[] Siding [El] Other [E] 1/44;11A—Ati(1;4$1761--(- ..
Brief Description of Proposed r
W ork: t i° rK? - re lrl ( ot .3ea, 7 /-7/� zi-aer € J Q,�%1.e" ' 1`J —%& ' 4C. C t�G'i i"
Alteration of existing bedroom Yes j No Adding new bedroom Yes v No ik' �` `
Attached Narrative Renovating unfinished basement Yes y - - -- No
Plans Attached Roll - Sheet
6a.. New= house-artd or addition to,existinq.liouslnq,:compiefe the'folloinr rig:
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. 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 . City Sewer Private well City water Supply
SECTION AUTHORIZATION--TO - .BE- COMPLETED: WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, /� , as Owner of the subject
property /
hereby authorize ' ' _ , C ‘
t ct on my behalf •'• _ � r.—.: ... �.,..- to work a . . zed by this buildin permit application.
Signature of Owner / Date
I, /'t Z/: Ce , as Owner /Authorized
A9 Y e nThereb decla hatthe t ements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed and the pains nd,nalties of perjury.
fro ne _ey/
Print ame
Signature o Owner /Agent" Date
i
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size w.._.m__
Frontage - - - -- — - -- - - - -- �.
Setbacks Front
Side L - R: R:
Rear
Building Height
Bldg. Square Footage i %
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 Q DONT KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
•
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO (2.D. DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 , Date Issued: ".
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO (2D
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, ex vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
s
Dep artment use only
City of Northampton s yPe
ot�Permlt
Building De partmen t . `Cuthcu1%Dnvewa y rrnit
•
JAN 212 Main Street e�edeptrc arlabtld
n
0 20 Room 100 W ?te ., g 9.9 f Avaabi],ty ." _
Northampton, MA 01060 T tivo e tsofSt cturafP
phone 413-587-1240 Fax 413- 587 -1272 • P! /slt e -Mans ;. v ..
j
Q t h Specify = .
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be , corrlpleted by o f f ic e
de/t //_ ;Map- - Lot Unrt
2// / p t) % S Zone Over Disteic
Y �� �� � ' " � D �� EImSt Distract G B bi
SECTION 2 - PROPERTY OWNERSHIP/AUTHO RIZED AGENT
2.1 Owner of Record: 7 �""
d� /r /e/�; .. ..- / � � r� �r 401 i� � i
Nam tint) Current Mailing ddress: IJ/f
Telephone„ /3 , JU 4 -- � �' 5.,
Signature ,
2.2 Authorized Agent:
/2,-/ ' 2 'e•-- -- 7 lit g,J .,Z /--
�'G�� f �l C' !' //' (.;>-)
a e P i r� Current Mailing Addre
7 ,„„... yF Signa ure T elephone
76_-,- Official Use Only
SECTION -3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Co st ( Dollars) to be
completed by permit applicant
1. Building /1'� ' (a) Building Permit Fee
2. Electrical (b) d o C
Construction from (6) of
3. Plumbing Building Permi Fee ost
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5)
7;----- ( Check- Number 76
This Section For Official Use Only
Date
Building-Permit Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2011 -0617
APPLICANT /CONTACT PERSON C & T CONSTRUCTION
ADDRESS/PHONE 15 Fairway Drive FLORENCE (413) 586 -4965
PROPERTY LOCATION 211 NORTH ST - UNIT B
MAP 25C PARCEL 095 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out r l
Fee Paid 7 76 055
Tvpeof Construction: RECONFIGURE OFFICE SPACE REMOVE & ADD NON - BEARING WALL)
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 062884
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 _ Permit DPW Storm Water Management
• • '.on la
411, Z /v.-7 /— /1-77
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.
NORTH ST - UNIT B BP
GIS #: COMMONWEALTH OF MASSACHUSETTS
L 095 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- 2011 -0617
Proiect# JS- 2011 - 001005
Est. Cost: $8250.00 .1
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: C & T CONSTRUCTION 062884
Lot Size(sq. ft.): 8189.28 Owner: APPLIED MORTGAGE SERVICES CORP
Zoning: URB Applicant: C & T CONSTRUCTION
AT: 211 NORTH ST - UNIT B
Applicant Address: Phone: Insurance:
15 Fairway Drive (413) 586 -4965
FLORENCEMA01062 ISSUED ON:1/19/2011 0:00:00
TO PERFORM THE FOLLOWING WORK: RECONFIGURE OFFICE SPACE REMOVE &
ADD NON - BEARING WALL)
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:
FeeTvpe: Date Paid: Amount:
Building 1/19/2011 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner