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DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR
'212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction super-,:s sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be,a one or 1►vo
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 6uil Ing department for ttte 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 regulation. 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 occupancv
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
w�L US understand the above.
(Home owner/resident's signature re westing exemption)
I will call to schedule all required building inspections necessary for the building permit
issued-to me.
D ate
Address of work
location �b � 5�� ( O(
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DEPARTMENT OF DUILDr,,IC INSPPCTIOt,'S
212 Main Street Nfunicipal Building
j Northampton, Mass. Q10G0
i
WORICCRIS COi ITENSA'nON LNSURA-NCE :'.1'II :.-V
(Ii�nscxJpc�mi 1Tc�)
v.r]th a principal place of bLlsinessfresidence zl:
(sa-��/ci rr/sZa.lcrri p)
Ido hereby certify, under the pains ad penalties of per3u , hat
( ) I am an employer providing die followine worker's comocnsz:ion coveMSC for ln�
elnplovccs �vorlong on this}ob.
i (Lr ur-mc Co=zy) (Pelic:?:u_-airr) -- (LE:-pirdor.Day,^.) "
{
( ) I am a sole proprietor, general contractor or homeow-Oer (c e c' one) and 112.\ hired
the consa(nprs listtd below wbo hive the following worker's cor-Or policies:
i
;
{ (Nam-, of Contnc-,or) (Instr3rI= Colnpan}1'1106c;NU4L?;) (Y :JI,dL•4n DBLC)
i
(fit:*nc of Conczcior) (insarne COMOalI-vJ?OIiC- `unC_r) (-Exp raon Dae)
(Name of Coaz2cidr) aa5w-an= Compamy/pol:c}• t•umb�r) axpirvoo Dalc)
(Name of Conaaclor) (Insuran= Company/Policy Numbu) (-Exp a:ioa Da1c).
(ncac3 x.d3i�oo1�rv,ifn�.•ti.u c.cu�iarorry+�on peas to.11 oc�-LO:-s) - _.-. _-
( ) I_am 'a sole propretor and have no one worlo.ng for me.
I aQ1,a home o.vner performing all the work myself.
NOTE:plex_sc be ew-are tb,wt:1e -t>o auplcy pctoas to cj:j rc;aa work on a d-11^z of
aot more th:a L---ors in Wb3e6 Ux bomeoAvc rand.=«oa the p-oua6 x7puttra_=th,--o 4z ox C==Dy to be
asiploy�a
um: the..ui•,cr3 ca=;> ica Aco(SL1152=1(51j appli=6aa by 4 bamu=w-oa fc r-y c id^ocr tbc
lepl r"^„oren eslloyx under da Workd.Compem.lioa Arm
I ynderz,od th e a ooyy of this ascmmx m.y bo fora nrd.d to tba Dap..lm�e or Inc riJ Acridaz:Offi th.
covcasc vclratioa-ad ttu L--iltac to seturt eovrciyt tmdc=c ioa 23A or).(oL 152 c=led to the in*SIIioa cf clmim�l Pctukia
o a s=i s t a g or a f t a c or up to S 1500.00 a:&Or or up to ooc year ead c�U pm.!-ua in'x tuna of a Stop Work Ord-- sad.
fries or S1 .00 a dey �.
. For d,,� =-'l use on17
Permit Numb=
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SECTION 8-CONSTRUCTION SERVICES ±
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
�.�tea�s"'le`�"se� orrrenipravemex ontra Not Applicable ❑
Company Name Registration—Num er
Address Expiration Date
Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCE AFFIDAVff°(M.'G.L.t.IwA 25G(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 1083.5.1.
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-vear 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 thi w.,
The undersigned"homeowner"c fi d es responsibility for compliance with the State Building Code,City of
Northampton Ordinances,Stat and State of Massachusetts General Laws Annotated.
Homeowner Signature
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑:: Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors 0
Accessory Bldg Demolition ❑ New Signs [0] Decks [p Siding[[--3] Other[II]
Brief Description of Proposed i
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa,#'f Nev��fiouse�anc�>,��dihorro�extstlixcouslng�:corr�e�e=ttieofavutnrl:
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 7a-OWNER AUTHORIZATION-TO BECOMPL ETED WHEN
OWNERS AGENT OR`GONTRACTOR APPLIES FOR BUICDING�PERMIT
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.
- a
Signature of Owner Date
l 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
Signature of OwnedAgent Date
—
Section 4. ZONING All Informatibil 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
Frontage
Setbacks Front
zo
Rear 7_1
Building Height
JA
Bldg.Square Footage 01/0 d
Open Space Footage %
(Lot area minus bIdg&paved OZ17o tet&0 toi- &V.
parking) l h&V
#of Parking Spaces
(volume,&Location)
& ' Perm�/Varanoe/Findi � ever been �suedfor/on theshe?
NO 6� D�7K�W 0 YES 0
~-- '
�
IF YES, date issued:.-
IF YES: Was the permit recorded ut the Registry ofDeeds?
NO 0 oUm'| KNOW 0 'ES
IF YES: enter Book Page'. and/or Dooument# !
'
B. Does the site contain a brook, body of water orwetlands? NO DONTKNOV 0 YES 0
IF YES, has permit been or need Lo bo obtained from the Conservation Commission?
-
Needs tobaobtained x_�x�� Obtained �~\~°�� Omma |osmm��''
C. Dn any signs exist un the property? YES K J NO
IF YES, describe size, type and location:
D. Arethen* any proposed changes toor additions of signs intended fo the property? ,Ex 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb
K�
.ov@hng>ovor1on�or�dpodof000mmnnp�n
�o *iUdi�urbovar1ane? YES NO �
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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City of Northampton ..`
e
Building Department
212 Main Street *
Room 100
rfT,111 Northampton; MA 01060
phone 413-587F1240 Fax 413-587-1272
APPLICATION,TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 7• SITE INFORMATION
1.1 Property Address: This section to be completed by-,o ffice
INUM
� ryry
i1/ �JJ�/�" �^�V t
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SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
o 5 10 (Ak(,;vkt-)01 , ��
Name rint) Current Mai' Addr s
IJIN_
Telephone
Sig iur
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
2. Electrical w -(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) �U Check'Number
- This-Section kir Official Use Only
Building Permit Number- " Date ,
issued:
Signature:
Building Commissioner/Inspector of Buildings Date
gibe#BP-2006-0547
+ APPLICANT/CONTACT PERSON REYNOLDS CODY
ADDRESS/PHONE 40 CRESTVIEW DR FLORENCE (413)587-9891 Q
PROPERTY LOCATION 40 CRESTVIEW DR
MAP 29 PARCEL 452 001 ZONE URA/WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid TIV
Typeof Construction: ERECT 20 X 10 SHED
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
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 Stree Commission
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.
'40 CRESTVIEW DR BP-2006-0547
/-#..
COMMONWEALTH OF MASSACHUSETTS
MaD:BIjkk: 29-452 CITY OF NORTHAMPTON
- 11 40
L"ot. -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0547
Project# JS-2006-0801
Est.Cost: $2600.00
Fee: $25.00 r PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10018.80 Owner. REYNOLDS CODY
Zoning:URA/WSP Applicant: REYNOLDS CODY
AT. 40 CRESTVIEW DR
Applicant Address: Phone: Insurance:
40 CRESTVIEW DR (413) 587-9891 (1
FLORENCEMA01062 ISSUED ON:1112312005 0:00:00
TO PERFORM THE FOLLOWING WORK:ERECT 20 X 10 SHED
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector-oUPlumbing- ---Inspector of W-icing - 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 11/18/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo