36-034 Critp of Wort4amptan
� � �tassachiisctts -
DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building °�., 5 •`
Northampton,MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as 1-:is/her construction supra.,,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 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 rouEh 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
r
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} 6 Fi�aseacilnsrtIs'
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^z m DEPARTMENT Of' EUILDr1,,'G INSPECTIONS
212 Mimi Street ' Municipal Building j
Northampton, Afass. 01060
WOREER'S COMPENSA'T'ION INSURANCE AI FEDAN717
\:ith z principal place of business/re:idenc
(strceUci t•;i sty t_:�•�P)
do hereby Cer-Lif: tlIl:'cl" tl1C 1) ii]S :?i]C pail;itiC i pi pC.'quf)', ina",
O I am an compensation covera`ve ;or Iny
elnployces wori-ing on this job:
(lnnrrarla� Comp.m') e c N L ZErr) --- (Fx-p;rr:acn Date)
( ) i az-i a sole proprietor, L;eDPral c-sa c cr hor-'to-wner ;circle one) ?nd 't:a-',-e hired
the cof]uactors llste,G belo\'r\clip il� ili iOJC v.'OrkP-'S GJC °11 Oii `s0!iC'.CS:
(Name of Contactor) (LnEL-:ncc Corrran;:Pclicr NLu11t--r) ;Lx;�.:-raion Datcl
(Name of Contactor) 7lisar,_rce Com:)allv pohm N + tr r) (l:x r.::in D.Date)
(Name of Contractor) (In;Ir ulcc Com;:anl;iPolic; Nun h-a-T) xi-': n Date)
- (Name of Contractor) — (Insz ranee Cotnr y.P olicy Number*) Dare)-
(.^.[LIGl aff�Itl OC:1I f_:CCt ...�_..- :O ..r...,... ....'Y:^.1..Cit r-...._-._:S;f ..•.li-.�.SO.......)
l I iun a Sole prol)fletur i'.?fQ havC I]O OIle ••'•oFk1I]i! lol- 11-i -
I :?ill a home
NO ITi:plc x Lc nti.n c t4s!.�i)c Ixcr�o.;r c: l y i n<:: r�ncc cz:.an m a':-,a r« clli c.
not more th_n throo ttni+,I in tai c+t Lhc-'O=c r t -ssll:i
cmployc-73 ucr'rs th wcaxr s $.—a!im Pr.((3t.!52 s!(5);.'.ri:- ,
.,c:;by a ho::�rotv�ur for=Lax c<p:rr:....
legal etatuc of as employer under tlrn Wcvkcla l ocL;:writiOr !.cL
I uz�dc.-rta.nd thif a cry of this ctat=—•cuy to forwnrdS j to ti» for tlx
Coverage vcr&crlioa and that failure to 25A of MGL 152 can lmd to the i-mr asition oCC"�
��
cvaiof 51 .a Ctrx of up to S 1 SQU,CXJ n:t�' r i^:r. r.�ti.1 of up to or._}- ,.-.j civil xzu16 in 9<fc,rrn cf n S!r. ,•^Y- -=r.3 t
Lr>r oCSIlT�.00 a day ars.ina m.. .
' CoC l u.c oily i
�Jc�- -2.11 Pcrrnit Numiny
S i'naturc of at
SECTO�tB CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Imrm-A 1.u Nil XJ
License Number
Address Expiration Date
Signature Telephone
Regs e e b pxovernent ontracto Not Applicable ❑
o��� e.c'►?a � c�G�',o I-L13L,`�
Company Name L Registration Number
_ o �C�S> S� LC►S�1r�,rrl��res,. �� hl on
Address Expiration Date
Telephone X13 S37 -�j`IG$
SECTIO l0WQRKERS' COMPENSATION 1NSURANCE'AFFIDAVIT(MG.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.......0161 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 La-,vs 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
nSEC'ION . E5 fit= ION(�FPROPOSED,,WORK checkll a Ilcable
Rp,
Nz
ni
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding[ ] Other [ )
Brief Description of Proposed Work: s F ,'n IRL Q
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet 0
6a: = _ ;Meant 0 U—STel M orad�:itron toexisfing h uo sin'"gc mo plefiefollowin
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. Mascheck 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 Nc
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
ECdON� YV fRAUTHO�RIZATION 70 B6-COMPLETED WHEN
OW,NEIS AGE T�]2CONTRACTOR APPLIES FOR BUILDING PERMIT
S AN
I' v , as Owner of the subject property
hereby authorize to ac; or
my behalf, in all matters relative to work authorized by t is 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.
�-GGicl��d���Jltllu
Print Name
Signature of Owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to b'e filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
azkin
#of Parking Spaces
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:
! i of Northampton
!�q. llding Department
OCT - 5 2006 12 Main Street
Room 100
orth mpton, MA 01060
_phorne
3-587-1240 Fax 413-587-1272 P .;
- --— .�
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - S'ITE INF..ORWTION
1.1 Property Address: s sec#io `to b comp a#e b: Af�ce p
iC
Zone`= Overl a"s#ri_c#
'
EImY District - fr CBistricM
SECTION 2 - PROP ERTY /A
OWNERSHIP UTHORIZED AGENT
2.1 Owner of Record:
Na
n4 e(Pr' t) Current Mailing Address: '
S`�1 -•s5`-I i,
Telephone
Signatu
2.2 Au orized Agent:
_�.Awo,;4-c C'v?Iv N i b �_�•9S� S� �hAw aN
Name(Pri rI.P T Current Mailing Address:
lz�_Z, l SK) — 11LIol
Signature Telephone _
5ECT10`N 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building 4S oo (a) Building Permit Fee
2. Ele-rical (b) Lstimated 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
This Section For Official Use Only
BuildingPermif Number: Date Issued:
Signature:
Building CommissionerAnspector of Buildings Date
3 WHITE PINE 15R BP-2007-0386
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-034 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit# BP-2007-0386
Project# JS-2007-000573
Est. Cost: $6800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: EDWARD J QUINN 144548
Lot Size(sq. ft.): 11020.68 Owner: MURPHY JEFFREY S&CYNTHIA Q
Zoning:URA Applicant: EDWARD J QUINN
AT. 3 WHITE PINE DR
Applicant Address: Phone: Insurance:
126 EAST ST (413) 527-9408
EASTHAMPTONMA01027 ISSUED ON.101612006 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & 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:
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 10/6/2006 0:00:00 $25.001129
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo