32C-214 (5) j�• Critlr of 3Kartllailiptoll
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DEPARTMENT OF BUILDING INSPECTIONS ' l�
INSPECTOR 212 Main Street * Municipal Building
Northtunptom, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as l;js/her construction sup : . sor. T h�.- state defines "Homeowner" as Person(s)
who owns a parcel on which he/she resides or intends to be, a one or tivo 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, ),o U e jt,-)Co GU 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 7- /- 0-3
Address of work
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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
9 -`Registered Nome (rrip`ravemenf`Cofii:kf Not Applicable ❑
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...... ❑
11�� R'o'me OwnMer I Exem`ptlon
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2) farniiies
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 Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House El Addition O Replacement Windows Alterations) C Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs ( ] Decks I ] Siding [ ] Other [ ]
Brief Description of Proposed Work: T.V�D/OU_-_-, _/)(1y eg _- '}s�tb��_ _cS 1R4 `?(1 . oo__&)*(_(.��p__- -
{J �J
Alteration of existing bedroom _ Yes I-- No Adding new bedroom Yes _-r/�No
Attached Narrative C Renovating unfinished basement Yes
Plans Attached Roll �-j - Sheet C]
sa. if New, house an&or 'addition to existing housin , complete the following;
a. Use of building : One Family -_ Tv.o Family -_Otr,er
b_ Number of rooms in each family unit:_ Nurl"her of B t'nrooms
c Is there a garage attached?
c. 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. _ __._ P^aschec'r, nergy Compliance form attached?
n. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No Is construction within 100 yr floodplain _- _--Yes v'
I. Depth of basement or cellar floor below finished grade
K'. Will building conform to the Building and Zoning regulations? 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
&11,),a yo -- ----. - - ---- --- -- --__ -- as Owner of t'ne subject
hereby authorize ___ �'� _ - - to rc
�,w behalf, in all matters elative _o work author ?-_d hv 'h - r ra.t,r,n -_ .--
I
Signature o Owner e
, ,d-VAI-T __671/Ge 'rd --_ __. --, as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of rry
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
Section 4.
ALL INFORMATION MUS'h BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
[wilding Department
Lot Size
i
Frontage _
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces 3
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 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 DON'T 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: ___
r Depatr3 entuse�rily
pity of Northampton Status o€ Permits
wilding Me De Curb Cut/Drtvewayermlt -fig
ti X212 Main Street Sewer/Septic Railabi�ty � �� � '
Room 100 UJaterlWel!Avaalabtlity,x*
�l � � n � 'A�
orth`r mpton, (MA 0 00'0 Two"Sets of Strilctura! Plans
u; 58 -1240 Fax 413 5 1Piot/Site Plansr�
Other Specify,
k
CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
3
SECTION 1 - SITE INFORMATION 1
7.1 Preperiy Address This section to be completed by office
Map_ Lot Unit
Zone _ Overlay,District
Elm St. District CB District
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
- 4006
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�hGm,67�Y? _ -f0e_OVl�1
2.2 Authorized Agent;
I
I SECTION 3 ESTIMATED CONSTRUCTION COSTS
Istimated Cost (Doll, tc Official Use Only
completed p
leted by ermrt
Pt-nnit f=ee
r /
i
Total Cost of
s !',ctlon from 6
Building Permit Fee
Nwnber
l ,
F Protr�t�on � _
- --i -- — - - - j -- -- — ---
-
This Section For Official Use Ong__ _-
Building Permit Number:` _ __ Date Issued;--_-___-`-
S of 13u Idings to
35 HOLYOKE ST If BP-2004-0003
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32C-214 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildina
Category: BUILDING PERMIT
Permit# BP-2004-0003
Project# IS-2004-0003
Est.Cost: $1100.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa.ft.): 3789.72 Owner: EDWARDS LYNNE K
Zoning:URC Applicant: EDWARDS LYNNE K
AT. 35 HOLYOKE ST
Applicant Address: Phone: Insurance:
P O BOX 1513 (413) 585-9897Q
NORTHAMPTONMA01061 ISSUED ON.711103 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP, PLY & SHINGLE ROOF
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: O k f( (.3-b3 4 w
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATIO OF
ANY OF ITS RULES AND REGULATIONS. ,',
Certificate of Occu an nature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 7/1/03 0:00:00 505 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
Now