36-020 p4•(t1AA1P�0
Gl ity of Wart 4amptan
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DEPARTMENT OF BUILDD`,1G INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building
Nortlmnpton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction sup<:,•i sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or twofi-MUTY -
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, 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
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a E Crif� Pffiarfffailt}ito>> _
g � �;asaiccflasrlln'
w v DEPARTMENT OP BUILDING INSPECTiot.'S
212 ]lain Strcct Municipat Building
Northampton, Mass. 010GO
WOMCCR'S COI1\1CPENSA-MV MSURAINCE AFFIDeivrr
%,.rich a principal place of businessfresidence at: -- --
(phonei!) 167
(sn-rst/ciO fa p)
do hereby cerdfj;, under dic.pains and penalties of pegury, llal
am an employer providing the follo.ving!worl:cr's cosnocns-:iO cove: for Inv
emptoyces worUng on ttlis job:
(tom--nom Com=-Z\,) (PcUccr Niumbcr)
O I am a sole proprietor, general conu-aa.or or homeowner (c cie one) and have hired
the coaractors listed+ below who have the fotlo%vino worker's camoert_t2 jon policies:
(i+aR1C Oi CoR'_^Ctor) (IRRlranc: Coinpan -Pi obcy NU.QLC:) (`;JITW,01- D.ILC)
(Name of Coatraclor) (]nstuznc: C0m0azv1?0'c- \umcrr) (E-,Dir.6oa Date)
(1 i me of Cooaaao,-) (I.nsur-ancc Ccmpaziy1PoUcy N:rs1W) (Ezpirllea Dalc)
(I`'une of Coaoraaor) (Insufan Company/Policy Numb r) (Expitaaoa Darr).
(aIIli,3 adu�oca!z5cct,ifococ��_-r-ca c�cu iarbrm-aoo pcati,aiac to.L Dons-to:�)
O I am'a -sole-proprietor and have no one wort ng for me.
( ) I am.a home owner perforTaing all the work myself.
NOTE:plc be cw-Am tfi••K WC bcco )-m bo pazpl-! play IO do = c=�—zc.oa c rgaa waric an a d. _U,-Z of
ant taorz than tL—tmctr in 1-b ch the bornoowoc rcaido cc ooh.U xs ,gpt�tbeau a-c ox C=). ly oeczedzod to be
eilploye�unc'e the=i—ec=P=—z,-oo Act(GL152.n t :.{iplie3,6oa by a homco-Da far a liccr_=a PC-=it rz=y a 4dco-t•
Ic-PJ rtanre of ea cgloyx under dw Woricoe.Go¢�om.yioa AeL
("04ary and tha a O-PY of thin mtemcm my be foes,f d to tbo D p_,ean of lod+,xr;er Accdeat='OM—of La.+r.oeo foe tb.
cova"_L; v 'G=oa and tt=at Ut:m to Lc=m lenvera.so tmdc==oa 23 A of MOL 152 exn Icd to the union of cimiajl pea+hio
ooaxiamg of a rive of up to S I}00.00 an=d/or 6asP60ama-y of up to roc)-=r e.od a%il pmiltio io 6c form ora Stop Work Otte and a
fiao 0(:S 100.00 a d_y dpi=me
For u.c only
Permit Number
S,g�aturc of Li�scc/Pccrni u e __ •l
SECTION 8-CONSTRUCTIORSERYIPIES' r
8.1 Licensed Construction Su,yeervisor: Not Applicable ❑
Name of License Holder: tJ L''
License Number
Address Expiration Date
,� nl >� . �a •�' � �d � �-d�- oaf
Signature Telephone
-1116 7
11� Re sieve �o tam"" �i^i r b' &-1 %&4611 Not Applicable ❑
Company Name Registration um er
640 doLi� s'
Addr ss Expiration Date
L,712,T/-4 -OS Y19 Telephone sV .,y,1,;7 —'loo
SECTION 10-WORKERS'GOMPEIYSAtI N IIVSFJFMCERFFIp AVtT(Nt:G.L.c:t52„§25C(&jj
Workers Compensation Insurance affida must be completed and submitted with this application.Failure to provide this affidavit will result
in the denial of the issuance of the buil ' g permit.
Signed Affidavit Attached Yes....... No...... ❑
,
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. . WORN
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/sbe 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
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SECTION 5-"DESCRIPTION<OF PROPOSED W.ORK(check•allapplicable)
New House ❑ Addition Q. Replacement Windows Alteration(s) ❑ Roof g El
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[ Other[C]]
Brief Description of Proposed �-� rR�/ A) .� I 5 l�} //L,
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 Meva� o�rse��rr .�x '` tcan�`taxcs �c�a slnc�«compEe�e� a�"�our�lncl:
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 6BE'ICOMPCETED 3WHEN: -
OWNERSAGENTORCONTRACfOR"i4PPLIESFQR:BCJIC3DINC PERMIT
as Owner of the subject
property �- L 13 hereby authorize �� �
to act on my behalf,in all matters relative to work authonz d by this building permit application. '
Signature of wner Date
t o L- 13 t A'10 as Qtr/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 penal-ties of perjury.
Print Name���"
Signature of(&Wlkr/Agent Date
s
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 1
Side L ' { R:` 1 L'`. i R:l
Rear
Building Height
Bldg.Square Footage % —� F
Open Space Footage %
(Lot area minus bldg&paved L_!
parking)
#of Parking Spaces
Fill:
volume,&Location) j
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW Q YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW Q 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 Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued: j
C. Do any signs exist on the property? YES 0 NO 0
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 0
f
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 0
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
e
iQty of Nortf ampton
- ,Building Department
212 Main Street
Room 100 e
Northampton;AMA 01060
phone 413;587- 240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIONA-SITE INFORMATION'
� This sect�orr>wt��he com'pteCed°bgofE[ce � �`
1.1 Property Address: k
Zone' Overlay Distract
�O .02- 0 )C)6:2-
EtrttSf Distract CB Q4stncts
SECTION Z-PROPERTY;OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Prin `.7 1 -1 Curren g6 liar 9 Ad ss
Telephones-,
Signature + l J
2.2 Authorized Agent: ,l
,67, ,:fi) PJ L TS
rZA
A:), ,► L,, JW 1�j yr, 0 k)
Name Print) Current Mailing Add ess:
.h--- 6'94 '1116 7
Signature Telephone
SECTION 3.-ESTIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Buildings (a Building.Permit Fee
2. Electrical �r (b)Estimated Total Cost of
Construction from 6
3. Plumbing r Building,Permit-Fee
4. Mechanical(HVAC)
5. Fire Protection
c
6. Total=(1 +2+3+4+5) 6 - C heck Number
Thin Section Foy Official`Use Only
Building Permit Number' issued:
Signature:
Building.Commissionedlnspector of Buildings Date
11 FOREST GLEN DR BP-2005-0958
GIs#: COMMONWEALTH OF MASSACHUSETTS
MU:Block: 36-020 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0958
Project# )S-2005-1331
Est. Cost: $4800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq. ft.): 14853.96 Owner: O'DEA ROBERT L& PAUL R
Zoning URA Applicant: B & R Siding
AT. 11 FOREST GLEN DR
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586-4167 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:4111105 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING
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 4/11/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo