29-254 (5) �T t1AM p�,
Lrz#p of Xort amptmt s
� j11Zi assac3�usrtts
t DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR '212 Main Street • Muuicipd Building •`
Nordiampton,MA 01060 'M 5<
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supc:" sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or twb_ vnz y — -
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 fegulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfiIl),
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
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
F E V If of '�LINTc rf 311143t01_1
R J E �7azanchncctle' -
4 o
DEPARTMENT OF BUILDr)\10 INSPPCTIOI.'S
212 Main Strcct Municipal Building
Northampton, Mass- 01060 "
WQR..11L' R'S CONfPENSA`I f ON »SURA-NCE Fi'11JA-VIJ.
j
(1i J PC=
�ttcc)
principal place of businessfresidence at: - -
(l none')
rJ tS,=':d P)
do hereby certifj under the pains and penalties of perjury, hal
j ( ) I am an employer providing the foIlowinQ'workcr's cocnocnsaoon covem-e for Inti
emplovecs woriong on tilis job:
i (Iasuran=Comraml) (Police:i;t ter) -- (E-xpiravor,Date-) =
( ) I am a sole proprietor, general coiar actor or homeowner (c tie- one) and Dave hired
the conuaCgrs listed below who hive the `oUocviDQ worker's cCmJep—ta::on policies_
(L;=c Oi Cont ncior) (IRSLr311c:. Comparlypi oUCf ?gruzibc:) (R:•J1rduon 011c)
(Name of Conti:clor) (Lasurane:. Comoam-1poum, `unc^r) (L-%Diruon Dace)
(Name of Condor) Cms ran= Comnany/Pobcy Numbct) (Expirslioa Dalc)
i
(Name of Contractor) (I.osu=c-- Company/Policy Numb r) (Eapir-ddoa Dale)-
(aIIa41:drocil r �d.irncoci_-ti•w c�cvc�iafocti3+-:ioa peuinias W.11 occ-soz)
{ ) I am a sole-pFOpnetor and have no one working for me.
( } I am.-a home owner performing all Lbt Nvork myself.
NOTE:pl=7 be cwzrt o-"-tea bcmcrncu -bo caploy pc-.-oaa to Qi Ocr c_ r�ao c rcpou we c ca a 6.1 of
not mere t]L d=--traits is v�cb the oc oa the 17,=.6 zppu r%c th"::.,ox C_,.rDy to be
crplo)—11 the w=- =e--c=p=•,:ea AG(GUI 5L=1(3)�=pp(icL6=by a bom00%-oe fc c he---«pa-mh=y c,-kk==the
IcV2J et.==of ea ePloyx under dao Wockmet Coa om.tioa Aec.
I uodcrr.cad tb.a>oopy or thi. my be for--xi-d tc the 1,�-cgarua,-0¢of In�.sriJ/vedo��'offs-of tswcoca ror 16.
c ov='2�^c veiGetioa ud at--t L-.Lltae to A. a bove:ng-c uo&-.sxtioc 23A of),(01-132 c=Ic_d to the im;xmidon of mmicA peaalt c,
corm:.!=$o(a rinc orup to s I}oo.00 aadfor impruomoe"n of up to one ycr and aNil pc=aP.=is t5e form ore Stott Wort;Ord=and a
Ci=o(S 100.00 a d:y LpS ca me
For dgcrz--e��u,e oaty '--•-
Pcrmit Number
Lot
S i?-IInnb Ire o II-ic'rr�w-tPr-....:rr.-�
NOW
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SECTION 8-CONSTRUCTION SERVICES a
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
S�Re r leredHonreli �avemec .Co�fracfa •F Not Applicable El
Company Name Registration Num er -- - --"
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCEAFFIDAVIT`(M.G.L.c:-152,§25C(&))::
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...... ❑
t : 36mev +
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 � /'��4—
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SECTION 5-DESCRIPTION OF PROPOSED WORK(checkalFapplicabie)
New House ❑ Addition ❑:. Replacement Windows Alteration(s) T ofing
Or Doors IR
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding 0] Other.]
Brief Description of Proposed �.
Work: C.C{£N 1 N c twl�ic
Alteration of existing bedroom Yes X No Adding new bedroom Yes k No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
t -'' :!axe�. +'� -.rig= 's.� =, y`�az'rm5 zx';rtr'y,.- fir" _ ;.�- .,,'{e`•�!
sa �f Neves:tbuseyah-d'Vo� dr#iaft tam ilici[iaiisl�ra.., oi�ils�e�e. i f [owi g:
a. Use of building: One Family X Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached? tJ6-
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? :E 1,(CT 21 (, Fireplaces or Woodstoves ® Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction F!?R VV 1
L Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain Yes X No
I
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? �G Yes No.
I. Septic Tank City Sewer_ �__ Private well City water Supply
SECTION Ta-OWNER AUTHORIZATION-TO-,BE.COMP.LETED. WHEN
OWNERS AGENT OR CONTRACTOR APPLIES.FOR BI JICDIG PERMIT
l 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
JA V&C"$ pe uie yz-S 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.
TA KA- E01.)C 12-
Print Nam
0713,0 /0
Signature of Owner/Agent Date
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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 v�I Lyj�
Setbacks Front
----
Side L:' :L0 R.'�' L:` R:! ^�
Rear
Building Height
Bldg.Square Footage ; % —�
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill: t
(volumef&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
N0 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 j Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Date Issued:
C. Do any signs exist on the property? YES l0 NO
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 Q
z
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 . NO Qc
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Building Departments
212 Main Street
I, Room 100 er er�aaitF�
Northampton; MA 01060 ctiatans� -
phone 413-587-1240 Fax 413-587-1272 ftoS ara �w� � �
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
t 4��.'
-SECTION'1.-S1Tf IhtF6lM�4'F1APf
1.1 Property Address: d byoifice
This sectton to be complete
t�U&ii. jam' rI VR N[ap Lot Unet
rL n Overlay D�sfrrcf
f'l �
EIm St.District C&Distract`
SECTION 2-PROPERTY'OWNERSHIP/AUTHORIZED AGENT'
2.1 Owner of Record: lJEt7
Name(Print) Current Mailing Address:
Telephone (A Z04
Signs re
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 5-0 G U (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing 0 '�, 5-06) Building.Permit Fee
4. Mechanical(HVAC) 2f
5. Fire Protection
6. Total=0 +2+3+4+5) O I dOU Check Number
This Section,For Official Use Only
Date
Building Permit Number Issued':
Signature:
1
Building Commissioner/inspector of Buildings Date
File#BP-2006-0361
APPLICANT/CONTACT PERSON POWERS JAMES&LINDA
ADDRESS/PHONE 109 GLENDALE RD FLORENCE (413)584-4204 Q
PROPERTY LOCATION 85 OVERLOOK DR
MAP 29 PARCEL 254 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REMODEL KITC1J,BATH&CHANGE DOORS
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 FO LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Co ssion
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.
85 OVERLOOK DR BP-2006-0361
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-254 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2006-0361
Project# JS-2006-0510
Est.Cost:$10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const,Class: Contractor: License:
Use Group: Homeowner as Contractor
583?? 9P Owner: POWERS JAMES&LINDA
Zoning:URA Applicant: POWERS JAMES & LINDA
AT: 85 OVERLOOK DR:
Applicant Address: Phone: Insurance:
109 GLENDALE RD (41 3) 584-4204-0
FLORENCEMA01062 ISSUED ON:101712005 0:00:00
TO PERFORM THE FOLL OWING WORK.-R E M0DEL KiTCH, BATH & CHANGE DOORS
POST THIS CARD SO IT IS VISIBLE FRONT 'i".11. ST REL'1:
Inspector of Plumbing Inspector cf Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: house# Foundation:
Driveway Final:
17
Final: o'�`' I �'c�,l�� 1� Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
;:our'•: 9 ^•*• �-:c�a!rtirn:
a" J
Final: U't / � ��` Smoke: Final: t=jr'
Y �1
THIS PERMIT MAY BE REVOKED BY THE ITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS
Certificate of Occu anc signature:
FeeType: Date Paid: Amount:
Building 10/7/2005 0:00:00 $50.00
212 Main Street, Phone(413)587-1240,Fax:(413)587-1272
Building Convnissioner-Anthony Patillo