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n 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 780CMR 108.3.4 to
act aS !.is/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 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 rouzh 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
j
Or IN) of Porillc111110011 �\
A l 4 �PllJ4R(I bfllb °-
w c� DEPARTME?,T OP BUILDFNC INSPPCTIOt.'S
212 Alain Strcet Afunicipal Duild,ng
Norlhamplon, Mass. 01060
«`OP-jCE Z'S CO!'II'ENSATION -MSURk-NCF AF DAVIT
{li Ccnsxl()crm�ttcc)
\%rIth a principal place of businesslrcSIdence at:
2,5-1 /Q 6LA"1 Gi '4 t 3.5�M Q Z 7
do hereby certify, under the pains and penalties of perjury:, .11.'.I
( ) dng e olowine , or c concsa�on covec I a D - employer provii Ior lny
etuplcyccs wor-�Dng on this job.
(Lsur- Conr<s�) fPeLic; ? ter) -- (r
( ) I am a sole proor;ctor, genera] contractor or homeowner (cc:e one) and have hired
the Conuactors listed below Who have the following Worker's ra�oen��on policies:
(Name, 0. CO"'-!c -) (111R'f'nc- Date)
(Name of Cona"aczor) (Lnsurane: ComDan`i?olic- \umcrr) (l soimtion Date)
(N me 01 Con>saclo,) (Lasur-anc: Companyfpcbq- N,lsl'--r) (Expimdon Datc)
. I
I
(Name of Cona-acter) (Insurancz- Comrauy/PoLIcy INumbz-r) ( xpumdoa Date) .
(�rzc3�i�ocil cScc,il oc�� W ctc?t�iafort,7.._^.'cc P='t°'a'a6 to.11 o�-LO:J) a
I am a sole proprietor and have no one wor'�ng for me.
( ) I am.a home owner performing all the work, myself.
NOTE:plc be cw-Lm 0.•kJ-j) bcc,1a,,,utbo c>�play pcurm t.o do � cr roan wcric of
noe rLOCC th--Lt--timij in u$ieh the '.da a oa the U'ou t zt-t�Lh- G "we C�-uy oL=,d-.d to be
ctplor--u-2—ibc k-ka- ---';m Aa(GLI 52—1(5)x z,)qd=ovu try e hom. --=fcr_bc--=or r»:ra_y c dam« 1v
)cam..!naau of ea ecployx under din Wore.ela Co¢:pom�tioa Act_
[uadcryzd lb->oopy of thi..cat® —y b<f----t-d to the DcQnrtmm2 of I:xSir;cl Accid ti Offioo or[r�u��°°rx th<
oovc�.b vc-6czlioo nad 0--I LIJUrl:to sec c 2S of MOL 15'1 can Ic d w the i-xp=itioa of c min 1 pcc'w°
coa-.i:..�cg of&6t of up to 51}00.00 a.'NCr i�it.oame of up W ooc Y'-1 LDd cNil pmiltio in t�form of n S`.oP Work ordc ead"
fib of S 100.00.d_y IptiaA trx
For 6q-nm='.'—oaty -
Permit i�tt:.mbcr —
1.,(�P^
S of L. cn' uc: e
0
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction1 Supervisor: Not Applicable ❑
Name of License Holder: �'(� 1 Vt n�/Vt 5 �/� e—, S
License Number
'Z- <7 4 9 0
Address Expiration 6ateJ
SAJIT5—kYre Telephone—�
9.'Reaistered Home.lniprovement Contractor Not Applicable ❑
117
Company Name Registration Number
7
Address Expirat on Da
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M.G.L.c.152,§-2SC(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...... ❑
11 -.Home Owner Exempt�ori
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 hirc 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
1
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing El Doors F-1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [CI] Other[lam]
Brief Description of Proposed
Work: A'P-W 12 AA, 6w
Alteration of existing bedroom Yes No Adding new bedroom Yes _ No
Attached Narrative Renovating unfinished basement Yes o
Plans Attached Roll -Sheet
sa:.lf`New-liouse.and or=aciciifiow oiext'stin�g Flouslnp.=complete`the;follow►ng:
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 Pdvate well City water Supply
SECTION 7a- OWNER AUT-HORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR"CONTRACTORAPPLIES FOR BUILDING,PERMIT
1, 1-1a%->V'-CA— /vt as Owner of the subject
property
i
hereb thorize 'Le(S -Jt6-"1 5
to ac on y half, in all matters relative to work authorized by this building permit application.
Si nat e of Owner Date
1, d--.Y'i SDII 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.
Print Name
[
Signature of Owner ent D e
=
-
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
Setbacks Front
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Vahunco/Findi been issued for/on the site?
NO 0 DON'T KNOW YES 0
IF YES, date issued:
L_-________�
IF YES: Was the permit recorded ut the Registry ofDeeds?
��
NO D
\_� mv / mvuvv 0 ,cx
r� ----'----| --� ---'---/
IF YES: enter Book Page ' and/or Document#�
B. Does the site contain abrook, body of water orwetlands? NO \��~� YES \_��
�
IF YES, has a permit been or need to be obtained from the Conservation Commission? `
.,
Needs tobeobtained /-� Obtained /-� Date
� ! '
�-/ \~� '
C. Dn an y signs exist on the property? YES /—� NO ~��\
IF YES, describe type location:
' ' �
D. Are there any proposed changes toor additions / l NO
IF YES, describe size, type and location: '
E. Will the construction activity disturb(clearing, gradinexcavation, nrfi||ing)over 1 acre oriah part ofa common plan
that will disturb over 1 acre? YES [ ) NO
|F YES,then a Northampton Storm Water Management Permit from the DPW isrequired.
Department;.use only .
City of Northampton status of Permit
� 1�6ilding Department Ctirb�utlDnuewayPerrnit
--- 212 Main Street SewerfSeptccAualabrlitx
1 Room 100 WaterNVell Availabilit}r
t
N�hampton, MA 01060 7uvo Sets of Structural Plans
MAR
phone 43-58 -1240 Fax 413-587-1272 P.IotlSlte Plans
Ut
.., If_.� ,.�'If'i5 OtherSpecify
APPLltA_ TO-CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section sto be comp.leted by office
1.1 Property Address:
Ol A�� Map "Lot Uni#.
-� ( Zone Overlay-Drstrict;
6 E(m St.Distract �CB,District ;
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�t
Na (P' t) Cur1gt M�iling.Pd s: Z 3
1 S
Telephone
i ture
2.2 Authorized Agent:
V__ _T�&61AA,5,o fn- 5�7.�i�dk.'rC�1.�e_��F.t . L2 y�2✓�t l _ c� .
Na (Print) Current Mailing Address:
Signat e Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant -
1. Building 000 (a)•Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from. 6
3. Plumbing Zf O0b Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2+3 +4+5) Check Number This Section For.Official Use-Only
Date
Building Permit Number., Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2008-0773
APPLICANT/CONTACT PERSON KRIS THOMSON
ADDRESS/PHONE 257 MONTAGUE RD LEVERETT (413)549-1027 Q
PROPERTY LOCATION 26 DAY AVE
MAP 25C PARCEL 068 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out fog 0
Fee Paid
Typeof Construction: ADD 2ND FLR BATHROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building,Plans Included:
Owner/Statement or License 084152
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF,,AMATION 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 Commission Permit DPW Storm Water Management
Demolition Delay
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.
. ` BP-2008-0773
GIs#: COMMONWEALTH OF MASSACHUSETTS
,A CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2008-0773
Project# JS-2008-001194
Est. Cost: $9500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KRIS THOMSON 084152
Lot Size(sq.ft.): 8015.04 Owner: MEADE LAUREN
Zoning: URB Applicant: KRIS THOMSON
AT. 26 DAY AVE
Applicant Address: Phone: Insurance:
257 MONTAGUE RD (413) 549-1027 O
LEVERETTMA01054 ISSUED ON:312412008 0:00:00
TO PERFORM THE FOLLOWING WORK:ADD 2ND FLR BATHROOM
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 3/24/2008 0:00:00 $50.00771
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
�1� 6
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26 DAY AVE BP-2008-0773
G15#: COMMONWEALTH OF MASSACHUSETTS
Map:$lock:25c-Qss CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Pernut Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Cateeory; BUILDING PERMIT
Pen-nit# BP-2008-0773
Project# J�S-2008-001104
Est. Cost 9500.00
Fee:$50,QO PERMISSION IS HEREBY GRANTED TO:
Con1st.Class: Contractor: License:
U$e Groun: KRIS THOMSON 084152
Lot Size(ssa.ft.); 8015.04 Owner: MEADE LAUREN
zoning CURB Ainr�licant: KRIS THOMSON
AI. Go DAY i6l
Annlicant Address: Ph Insurance:
257 MONTAGUE RED (41:3)549-1027_Q
LEVERETTMA01 054 ISSUED QN 3/24/2008 0 00:0(1
TO PERFORM THE FOLLOWING WORK.-ADD 2ND FLR BATHROOM
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:" !louse# Foundation:
4 }Yriveway Final:
Fina� Final:.
�tht 4S Rough Frame: Olt 0' 6(,�a If
Gas: Firg Degartment Fireplace/Chimney:
Rough: Insulation: /fir °l` aA y0)
Final: SMgke: Final:
THIS PERMIT MAY BE REVOKEOTHE OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULGertifiG to of Occ aC1C nature:FeeTytre Date
Building 3/24/2008 0:00:00 $50.0!)11
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo