25C-058 (3) O O
C-itV of Narf4a»tptan ,
�y DEPARTMENT OF BUILDIj\'G INSPECTIONS
212 Main Street • Municipal Building
INSPECTOR
Northamp(on, MA 01060
r r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/leer construction sup,.-: .- ,or. Ti he state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two family
divelling, 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 routsh 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.
Nome 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
A
6-ifl) Qf �l>_ rt1jullip till
� 6 JiiasaacVlasrtla' j^
IMPARTMENT OP BUILDING INSPECHONS
212 Drain Strcet - Municipal ,Builtlinl;
Northampton, Mass. 01(76'0 —
WORTQ�R'S COYIP�NSAZTON 1hiSURANC�: AFFIDAVIT
A
1C:nS;CJ�'CIiI11t1°�)
With a principal place of busulesslresidencc �?r.
-- - -- •;i IL.UCl I\ ... �"I t>1
aill -11t es 0--p(.1 ...._
( n an ctnpioycr providing the ii)ilovvitl(,'.�:tnr_cl _ coultuns<?u'.ln c.clvc:a.�c �o :i)y
enlplovecS Nvolkk llu oil tili;i job:
(Int�lianc Com. ""my) (Pciie:Nun bcr)
( ) I am a sole prol)lictt,r, general contractor or honleovvne: �circic ()ii,;) am }iaye iureu
the contractors Ilste,� bt'iov h0 11 \' the fol1G•:vlB wOrke-S
--_
(Name of Conti-;1C10 ) -- _—(111Slli'.nc:. �`011i^2 ir�i�011i;i N11i11C•:;l i,j.::;'::.. ..f. I)2lC)
of(,)I:II2CiQC 1 U1SlL1?IIC:, COIL�a .\'i1 0 1Ci
(1\lame of Contnicio:) (111su-ailcc Comp],-1}'lllolicy Ntljnl-�r) 'ti :i.:i:`:1 !_%atc.)
(Name of Contuactcr) (InSL1 non Coln any/11'olicy Nuint-:s) !' 1 1 Da(c)
(zttadt zbiitice:al rxct i'rc,•r-v:-::. :.r-..�.. .-:L<ru:i o(:� tai airy:.:eli��.<:-a�t:-1
( 1 wil It sUIC ;ilC)l)I]C::)i 2:I;1 have no olle for nle.
NOTE:p[czac be atvazc tl:a_
not zwxc th:n tltrco units in tairdt''�1::-a�i.ar rcr c�cr cxt t!�- :s z lurtm 1_`rcRo z:c[,X�crr:11';o.::::::c:i
catplo}�s u•i rz tlr«t.}:ct's c :�—.❑licn rr:(G!_lS?s!(S)l.r i: 'ic:by a hocsmc. r for n Lca_� c Irr :•c t:r_
Iegal rtntut of art onzploya under V:o Ad
1 uod,—^tared lha:z copy of this c2 atr.:u:t auy bo fotwnraiocl to tlr IY.Sn.L,c<,t of Izwt(u'rid Actin: 11f Of"-of I::auu.:a for tfw
00%,Mge vcrificatioo and tlut fzilure to!-care covetxbo urn r c.iett 25A of MGM.152 can land to the i:nl*,Stftm of c;v _!lxtsl::u
coalisting of a Carr_of up to S 1.500.60 a:k Cx- of up to Orr-r zr r.tij civil lxtuttia in�r i<'�n of a tit`-'�`' i ' A'
LF--of 5100.00 ►&V lg:61)a m--
i);natttre t1I l ic�n:;c:JPct; (lac. qtr• _ t
SECTiON`s =DESCRlPTlON OF PRQPOSED,WORK(checkxalfapplicable)
New House ❑ Addition ❑ Replacement ndows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
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
sa IffNew h uo sesand or adiiition;fo exastfnga;h°o'i i-ng complete th'f61RWinR:
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
SECTION 7a-,OWNER AUTHORIZATION -TO BE COMPLETED WHEN
6 1 NERS'AGENT OR`CONTRACTOR APPLIES FOR BUILDING PERMIT
I, / / as Owner of the subject property
hereby authorize to act o
y behalf, in all matters relative to work authorize by this building permit application.
Signature of}Owner Date
as Owner Authorized Agent
herd by declare that the statement and information on the foregoing application are true and accurate, to my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Narw
s�
Date
Signature of Owner Ag
N
f
r
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 be 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
parking)
#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
,-Tf`YES, date issued:
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 41 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:
y.�
1
r.
Cl112�f Northampton
Building Department .
�'L12 Main Street
Yn _ Room 100 a er W
J' -Northampton, MA 01060 e s o
phone 413-587-1240 Fax 413-587.1272 "Pilo /Site a r,
;T
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
Thissect�iloot a�b �cn1 0 e='om,p" ,bY0
;
ofice 1.1 Property Address: v ";01 Map
1141 a
Zone Overlay>DistnC.
Elm St. District C8 Dl's ir"' "
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: y�
me(Print) r,. Current Mailing Address:
Telephone
Signature`--
2.2 A thorized Agent: l
iAm
Nam 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 / , (a) Building Permit Fee
IV
2. Elecmcal (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
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2006-1142
G1S#: COMMONWEALTH OF MASSACHUSETTS
pp CITY OF NORTHAMPTON
�p
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-1142
Project# JS-2006-1690
Est.Cost: $1300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: Thomas C McCarthy 100364
Lot Size(sq. ft.): 20952.36 Owner: DUNPHY DEBORAH A
Zoning:URB Applicant: Thomas C McCarthy
AT. 25 LINCOLN AVE
Applicant Address: Phone: Insurance:
3 BRODERICK ST (413) 527-5141 Workers
Compensation
EASTHAMPTONMA01027 ISSUED ON:412612006 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 4/26/2006 0:00:00 $25.003985
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo