32C-156 (5) ¢TtIMlp�, ,
Cr if-g of 'Nart4aillptiall
9_2
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Nortliwripton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as has/her construction sup(;::'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
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 k/I �" ✓�tp
o C)6 c�
0
.a .°Euri� try �tiarfl�allt}�tfltt -� �_
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<� DEPARTMEbrT OP DUILDr�-,'C rNSPECTIOI.S -
212 Main Strcet Municipal Building
Northampton, Mass. OIOGO
«r O lUa,R'S C O NCP ENS A TZO N M S URAN CE A FFM A VIT
(liccnsxlpermitics) - - - --- ---
vVl h z pri,-tcipaI place of business/residencc at,
_ 'none.')
do hereby certify, under dic.palnS and penalties of pcg-wy; :hat
t -
O I am ao employer providing the following workcr's comocns-zLion cove age for Iny
etuplovices worlong on this job.
(Isimn_n= Conr,:-cy) (PcLic:N'u--"iy--r) -- (r xpirt;or, Dai_-)
O I am a sole proorietor, general contractor or homeow-cer (cisc?e one) and have hired
the conilaCgrs Listed below wbo hive the foko , )g worker's comae=saaon poicies:
([+Qfn: 01 Co„-^Cior) (t[1R13nt^ C 01npaJ1}'/!Gtici �ri1�1CC) \JlFJ 2^ DaIC)
i
(Name 01 Coaa-mor) Ons-w occ COMOaav/P01Ci Num6:0 (E.vpr.6on Date)
(Name 01 Coanaclo;) (Laurance Compao)-/Polio- Number) (Expimdoo Datc)
(Name Of Contractor) Unsuranc—_Comczny/PoUcy Numbcr) (E%piratioo Datc).
(aaacb:ddi�or31 thcct,ifnccci._�•tv atcfuci iafortai'ioa pcztaiains to all wo1-_c.on
I am a sole proprietor and have no one workz�og for me.
( I am-a home oivoer perfonumc all the work myself.
NOTE:plese be cwzrt tt,.4 w1 rc bcmco.m=uto cmploy pc Coat w 60 �_—.: a C rcRII..ork as r d..c1Lz of
ant most the LXc tVa is%cixch the bor000wvcr raids cc oa the Cro LOS zFulcn-rl tbeen rT o-x C==Uy oc=.daod to be
cixploycs ttn c the..- cr4 cc=p--•'ca Act(GLI52.=l(5)) =ppUca.6 a by a homco%-=fcr a hc=--cc perma r>_y c idmoc tL-
Icgir ctaa�c of as es=Ployx under dao wacky e.Coasp<ma=.ioa Ad
I u-d—xz d dut a copy of tbi.—=.=most may be fog--,-d d to the Dcp� OTof Iru+,+oc for tb.
covcrxn -a-;;canon aad the L-i=-c to soeurc tovcrn&-.tmdcr sxYioa 25A of N(CL 152 eaa lc-d to the ice,ns—o(cimiasl penaki-
cOcwz:it&of a floc orup to S I}00.00 and/or>x� oCup to ooc ycr Lod aNii pmatie in tSc focm oft Stop work Order and n
fun of 5100.00 t d_y tptin:a t>x
For u-only
Pcrtnl( Numb=
rEn xwrr 6 Liczmscc1Pcm)_iucc ��
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
4; Not Applicable -0
9 Reaisfered Elor►ie=lnae�orer�eriCotracto ES
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10=WORKERS'COMPENSATI"ON"INSURANCEAFFIDAVIT(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...... Ll
. M 10 iM
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 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 La and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5--DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs (0] Decks [p Siding[CD] Other[p]
Brief Descripti(Qn/of Proposed
Work:_ TN 5_l 4[/ 5c'A r- lve(tc'y CtZ�Q►�
Alteration of existing bedroom Yes No Adding new bedroom Yes _No
Attached Narrative Renovating unfinished basement Yes __,X._No
Plans Attached Roll -Sheet
mow. -
sa 1 Yernr tosser aDd®F"TO4 ices �rcc i si r�� of rp�e o 010, WM
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 stones?
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=-=OWN ER:AUTHORIZ AT,IOW-TO BE COMPLETED-. ,HENt
OWNERS AGENT ORCONTEAC-TOR=APPLIE&FOR:BUILDIft PERMIT;
1, r f �- 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, 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 Owner/Agent Date
M ,
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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage % r — —?
E f
Open Space Footage %
(Lot area minus bldg&paved [ i�
parking)
i
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW 0@1 YES 0
IF YES, date issued:; f
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW ® YES 0
IF YES: enter Book Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES i
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q Date Issued:
C. Do any signs exist on the property? YES Q NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,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.
w
en
1 it m�',Northampton S att is ofi +
—00 i q Department r� �
21 ain Street � �
SEP - 9 2006 om 100 mate
Northlampt6n, MA 01060 � � �� '
pfaone 41- 7-12 0 Fax 413-587-1272 � Stfe�ao
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION"1--SITE:INFORMATION,
1.1 Property Address: Th[s sect[on~to lae completeif 6yraffice ,.
�J 5 Map zQ4 Lat UnrC
` If h G �` ,�✓c9
_Zone!OuerfaD[str[cf,
� E St Distirct C
C Fltsteiet
SECTION-2-PROPERTY OWNERSHIP{AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) C rrent Mailing Addr��T olC-'60
(yi3Z
�j -! Telephone
Sign• ure
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)�Zuifding,Permit Fee
2. Electrical (by,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 L -.
This.Section For Official Use Only
Date=
BuildingrPermitNumber. Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2007-0261
APPLICANT/CONTACT PERSON JOHNSON ERIC
ADDRESS/PHONE 31 KINGSLEY AVE NORTHAMPTON (413)218-1072 Q
PROPERTY LOCATION 31 KINGSLEY AVE
MAP 32C PARCEL 156 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction:_INSTALL SOLAR WATER HEATER
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
IATION PRESENTED:
INFO
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 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.
31 KINGSLEY AVE BP-2007-0261
GIs#: COMMONWEALTH OF MASSACHUSETTS
:Block: 32C- 156 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-2007-0261
Project# JS-2007-000397
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.): 6011.28 Owner: JOHNSON ERIC
Zoning.URC Applicant: JOHNSON ERIC
AT. 31 KINGSLEY AVE
Applicant Address: Phone: Insurance:
31 KINGSLEY AVE (413) 218-1072 0
NORTHAMPTONMA01060 ISSUED ON:912912006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL SOLAR WATER HEATER
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:
FeeType: Date Paid: Amount:
Building 9/29/2006 0:00:00 $50.003234
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo