25C-136 ' 4'CHAa1P�.
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of Xart4ainptau
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DEPARTMENT OF BUILDIN G INSPECTIONS /=
INSPECTOR '212 Main Street • Municipal Building
Northampton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction supc.:1`sor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,a one or tiwo fame 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 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 roup-h 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
understand the above.
(Home ow /resid 's sig re requesting exemption)
I will cal schedu all re • ed building inspections necessary for the building permit
issued to me.
Date / l I%y 2 0 o j
Address of work
location
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l�o�t��►�.n •h MA
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z� 'otiE (riil,) »f �'Torfljuiu pfoii
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c� DEPARTMENT OP DUILDfNC INSPECTIONS
212 Alain Strcet Municipal Building
NorLhampLon, ATass. 01060
WOR =-R'S CONMENSA'ION GiSURA.NCE Al=I z'�VIT'
! I
«9Lb 2. principal place of businessfresidence at: -- ---
(phone:')
(sa twt/ci ty 15L11.c'a p)
do hereby certify, under dic.pa-ins and penalties of perjury:, ha i
{ ( ) I am an employer providing the followine'worl:c�s cocnocasanon cove age for Ind•
empiovices wor3ng on tliis job:
I
(Lusu sn=Comaiuv) (PoLic: Nu-err) -- (T=:-pir-,dor, D2L_)
II
1
( ) I am a sole proprietor, general contractor or homeowner (c cie or?e) aDd hzve hired
the contractors bsied below who have the '600::,ng worker's c=Den_,,adon pa!icies:
I
(Name of co„^ci0r) (1nSurancz_ Corcipa•-y'Pobc (EX7illrruuo?bate)
(Name of Conmclor) (Lnssraacc ComoanyiPolicl• \tsncrr) (Eavir,Lion Date)
{
i (Name of connacio,) (Iasuranc; CompanyfPobcy Number) (Expimden Dalc)
{
(Name of Contractor) (Lasuraacc Company/PoUcy Numb•-r) (Expirtdoa Datr).
(atla�l:�tiocSJ x.'ca,ifncccir�to c,c?vc3;�aform+�on p�1a'^'�w.11 oocrro:�)
i
{crl am'a sole proprietor and have no one working for me.
( 4,I'aixl.a home owner perforrning all Lbe tiuork thyself.
NOTE:plese lx ewzrt Lfir .tJe bcmco.%acn�i>o employ PK=-L s to do c reps work on r d.•Tus;^;:of
hoc wort th:a U v_-tests is-b,6 the bomwo ocs r=dcs or oa the souses zppu.rtcaarl tl,, r_z ooe Cr—.11y O , c--off to t+e
cutploycs 1, the.+ai ds O lin Act(GLIl 52,=1(5)�-.ppli=am by a bomcoava fcs c bc=_or pamit ra_y rvfd-oo<lbC
Icgl rtzlu of m er�loyx under clso Woricelr compceaalioa Au-
I undcct+ad tba x°pry of this mtcmcri m„y be forxavdod to tho Dopanmma Or1Od id A—d.=&OIL—of Iss ur• for tho
cover&c vain olioo and U-1 f:.iltae to 1-==tovernse under sor oo 23A of MOL 152 do Icd b tbo Lyon of m=ini!pea+llic
COMI tag of a fsoc orup to 51300,00 and/or o(up to voc yur cad civil pmalSim+a dx foccn or.Swp Wart Order sad a
fish o(S 100.00 s a:y LP C¢ me
For dcp.ne�=s1 u,c oril7 '
PcTmtt NUML---r
�'.(nP~-- Lot K r.
S' Li crmiucc Carfe j
SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9e sfeh otremvsr me €;od Not Applicable ❑
Company Name Registration um er - ------
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION:INSURANCE"AFF(DAV{T
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...... ❑
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 Zoni Laws and Stale of Massachusetts General Laws Annotated.
Homeowner Signature
t.•
SECTION 5 DESCRIPTION-OP PROPOSED WORK(check all'-applicable)
New House ❑ Addition ❑: Replacement Windows Alterations) Roofing ❑
Or Doors FI
Accessory Bldg. ❑ Demolition ❑ New Signs [E:3] Decks [p Siding Other[p]
Brief Description of Proposed ,C^off
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
�� �fN�oas��an � 'dio�<tO�;;�ex s inchioas��tcl.�co�nfete�hiTatin�>tnp:
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-OWNE,RAUTHORIZATION-TOBE.COM,PCETED WHEN
OWNERSAGENTARCONTRACTOkAPPLIES'.06 BUILDING-PERMIT-
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
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 an penalties of perjury. '
_
Print Name
Aa!/ 3 Q005
Signature of Owner/Agent Date
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Section 4. ZONING All Informatioh 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
{ I
Setbacks Front
-- r---;
Side L: R: i L:' R:i
Rear
Building Height
Bldg.Square Footage i % —' E
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 0 DONT KNOW 0 YES
IF YES, date issued:' I
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES
IF YES: enter Book ! Page; and/or Document# '
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
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 0 NO Q
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:
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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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��Ci€y oiNorthampton
Building Department
X005212,Main Street
MAY 3 l Rort oo
..
phorNortharpton -MA 01060
1240 Fax 413-58 7-1272. 413-58 r � �
-- � °
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION --SITE'INFORMATION
1.1 Property Address:
� : This sectton to be compleked by pffice
�6
r 42 &,bc
Zone Overlay Uistrkt
�-EIm SED�sYr�ct F -~ 4 CB,��skrtck
SECTION 2-.PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:oe
Telephone
Signature
2.2 Authori d ent:
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 `Sav (a)Building Permit Fee
2. Electrical (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." Iss ss Date,
. . ued:=
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2005-1212
APPLICANT/CONTACT PERSON GRAIFF JOHN G&GEORGE V
ADDRESS/PHONE 58 ELIZABETH ST NORTHAMPTON ()586-3748 Q
PROPERTY LOCATION 56 ELIZABETH ST
MAP 25C PARCEL 136 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction:_REMOVE ASBESTOS SIDING
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 F
OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF TION PRESENTED:
ed 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
4 AAP"�'X
ZONING BOARD PERMIT REQUIRED UNDER: § ,��i—/LG
Finding Special Permit Variance* Z„ .��•�/����
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
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.
56 ELIZABETH ST' BP-2005-1212
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C- 136 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1212
Project# JS-2005-1631
Est.Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group. Homeowner as Contractor
Lot Size(sd ft.): 4704.48 Owner: GRAIFF JOHN G&GEORGE V
Zoning:URB Applicant: GRAIFF JOHN G & GEORGE V
AT. 56 ELIZABETH ST
Applicant Address: Phone: Insurance:
58 ELIZABETH ST 0 586-3748 0
NORTHAMPTON MAO 1060 ISSUED ON.6114105 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE ASBESTOS SIDING (NOTIFY LANDFILL &
DOUBLE BAG)
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 6/14/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo