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DEPARTMENU OF BUILDD,10 INSPECTIONS
212 Alain Strcct Afunicipal Duilding '
Northampton, Mass_ 010GO
- WORKER'S CONIMENSrl`I'IO.N Ct'`ISLT CE AfTD):1.%r1-I-
Qi�usxlpermi tttx)
principal place ofbusinesSfresidence at:
(phone==)
(SUI=Vci ty/statcln p)
do hereby certify, under the.pam and penalties of perjury, ha t
i
O I am an employer providing the follovine''workcr's cotnacns-:JGP cove.10 for Iny
eluplovccs wol-Lang un drib job
1
' irtlon D� .
� (Lr`sul-:�c Conr,:��) (Folic:?tiu_�ixr) (T-:p )
O I am a sole proorietor, general contractor or homeOWTler (c cie one) aBd h2ve hired
the coon- tors taste-d below wbo have the folloVIioe worker's compen-sahon pokl'M
i
(11;a mt Of contncio') (Instranc.: Colnowly t�oUCi ?Mull)=<7) fYtiJlid 2Q? I�1lC)
-
j (Namc of Conrraizor) (Insattanc Comnan`i?oum, `LLm6:r) �apiraaon D.1e)
(Name of cournmor) Cl-asu-anc Compan}•/PoLc}•Nasbu) (Expiation Datc)
I
(Name of Contractor) (Lasuranc—c Comrasry(PoUcy Numbcs) (Expitaaou Date).
(nII1.eb �oeal r6c-.,tfnCC�--V to 6C GL eaf0et,..:ioa perUinia6 to.11 eoa:r-_e.on)
O I am a sole proprietor and bave no one working for me.
QQ I am.a home owner performing all the Nvork thyself.
i
NOTE:ples lx ea Nr tt,•yj }a hcmr very to employ peuroa en do eat-• Y cs e,Do c rgaa work oa a d..etl_;or
hoc tnoct the ` -=t-iu a-sch the bomoo-n rgido«oo the Qoua6,,.7p -•r_tb.-- o rz ax�SC1iy occrdaa!to be
eutploye s unC=the Dui ef: -+ee A=(GL!152.0 l(5)�_pptic�oa by s bomenaaccs fcc n ties_a Pamir try e zd=cc the
I--Sx1 cL--or en a-ployx uadcr d.Woric.alc Coo=pemai,iou Act
i
I uadecuaa s6a a Dopy orth;.eat,cmco;t=..y bo roe--,td to tbo Dopa imca¢orlaaux tJ Amda.&otsoo or In7'araooa for tho
cov=-' c vcrirolioa aid t1tr1 r_iltae to so=ot undo 1,0 ioa 23 A,or b(QL 132 eaa Ie.d to the imposidoa of aiminsl PcmxWa
ooau.mg*C&Tint or up to S 1}00,00 andlor 0(up to Doc
run orS 100.00 a d_y LVID:a the P )ter eod a�i1 pm`hia io dc form ora Wort Ordc aad a
.�• .. For dcp.na--r J v, only
Pcrmit Numtxr
` Vs N.(3P:" Lot,"
Un r of Lt�scclPCrrniUcc
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_ rity of J"orthai pion z
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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 78OCMR 108.3.4 to
act as has/her construction sups;::.,i ,or. The state defines "Homeowner" as, ' Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fami�
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 iegulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before back f1 1),
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.
(VWe owner/resident's signature requesting exemption)
I wi call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location AD_R..
r
+ ti
SECTION 8 CONSTRUCTION SERVICES +
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9wRe°isteretome'im�a e�trenLLarstacCar =' ry Not Applicable
Company Name Registration Num er
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...... ❑
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 Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature vl
r
i
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all'applicable)
New House [] Addition []:. Replacemen endows Alteration(s) Roofing ED
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0] Other[O]
Brief Description of Proposed -
Work: na-r'Tl1Y iA( 10 NecJ Reoi�+:e�►�I f tlle+✓`nt'�
Alteration of existing bedroom Yes _No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Plans Attached Roll -Sheet
to tf Neva kroase arcl or�actdtiQ tae%st� i0usnscot eta ttiecataui :
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-.TO BE COMPLETED WHEN
OWNERS AGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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
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.
:5- -cra 4
Print Name
Q12emirl2a.
Signatu wner/Agent Date
� .
'
°
, .
`
Section 4. ZONING All Informati6h 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
Rear
Building Height
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
Fill: F-
'
A. Has a Special Perm it/Vohance/Fndi ng ever been issued for/on the site?
NO 0 DUNTKNOVV 0 YES 0 �
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry o[Deeds?
��
NO �� DONTKNOVV 0 YES
IF YES: enter Book ' PoQe ' and/or Document#!
'
�� ��
D. Does the site contain a brook, body of water orwetlands? NO �~��� DON'T KNOW �_� Y[3 �_�
IF YES, has permit been nr need to be obtained from the Conservation Commission?
-
Needs tmbmobtained x�� Obtained �~x��� Date v�� '
�~�
C. Do any signs exist un the proper� �~� «�/� YES �~� NO
|F YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YE3 0 NO 0
IF YES, describe size, type and location:
E Will the construction activity disturb grading,excavation,or filling)over 1 acre oris it part ofo common plan
that will disturb over 1acre? YES K > NO K )
�� � `�'
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Nortpampton
` ilaing Department v ►
�( f ; 212 Main Street sew e e tt t t
- ,Room 100 �er
Northampton; MA 01060 .,s M
T�uu ,e s�Str�t�rral via i MY IN
) � � X11(' �`
U ht 413,5d7t1240 Fax 413-587-1272
p �
s.
ti Qtr'e~Speor r
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APPLICOJOTN,Tp CA�ISTRUC4,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1.-SITE?INFORMATION
1.1 Property Address: This section to be completed,by office
pftR i I>G�--J f'► Maw 1_0t, untt
Fv
���'QC � • Q Zone . Qverl ayrDtstnct:.
�ElrtrSt;D�str�ct _ .. _. yCB District_
SECTION`2-PROPERTY'OWNERSHIPfAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Curregt Ming Address:
Telephone
Signature
2.2 Au vorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTWATED`CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building I ,1 {,,{� 00 (a)Building Permit Fee
2. Electrical W , W W J Co(�(� (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) Check Number S This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature: !'
i
Building Commissionedlnspector of Buildings Date
9$DEERFIELD DR BP-2006-0052
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29- 172 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2006-0052
Project# JS-2006-0066
Est. Cost: $2400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sc.ft.): 16770.60 Owner: GROSS SHARON M&JAMES
Zoning.URA Applicant. GROSS SHARON M &JAMES
AT. 98 DEERFIELD DR
Applicant Address: Phone: Insurance:
98 DEERFIELD DR
FLORENCEMA01062 ISSUED ON.7115105 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 7/15/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo