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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 !-"s/her construction sups:-.•i .or. 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 roujzh 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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m DEPAu2T?ME NT Of' UILDI)�G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mnss. 01060
ti oma'R'S CUMT NSATTON INSURANCE AFMAVIT
O - - - -- -- --- - . - - - ----
N l,ila a principal place of busiresslr��:�idcnce
do herCUy CCI-CIIV% UIIa " LI1C hi:iflS 2Liti pci1:ci'Llcs Oi 7Cljllf-y,
I all zin cmpioyei' providing the iollo',•''i17f_ •.'OIt:C1`S COII1pCt1SaU0i1 GOVCr:2C IOi In}'
employees working cm tills job:
jzs- Ca -- Number) --- (E:�_rir,:Iion D2m)
j I am a sole proprietor, genera ccn=c,-er hocieo,,-veer (circle oriel and have hire d
COIltr`CiOrS IateC bZ.O�ti ';'lJ0 i? Cht `Orly .-�M2 ,'OritP�S G0 II?DenS-3 0r-1 C!iC'.cS:
(I`:a-me of Co!iCPCtor) (Insul...ac� l 01h^`:;ir':�O11Cf TflllIl)° r) ( = is �iil�')
(Name of Contrcto-) -- (.I-isur, nce Com:�ar v/Pe!icr Nuncrr) (E :air,tiny Date)
(Name of CoaLimmr) (I lsu i.c Coy an iPolic; Nurlllxr) ?x.:rtiaa Late]
- (Name. of Con.I cior) — (Ins,:i-aiict CoIIl1 yi oLcv Nt1.mJ.r) (,I.:.]! :ilr-Datej-
(^.I L3G3=.LS'�1:3 CY':sI S':_�t:...-._... ::�:.:_.�..�....'K:':1":�i•.�-.-.-.... � �.li:..�...-..--...-.1
(v<1 <Lll c1 solC pl"OI)I1 LJi 2111 it ? no ollc ,: ii` tOi Sit
1 affil ll 1101Z1e Cat'??Cr ti�l?C`Illll'" ait i_.., . ... ........�
cr
not UK<c th--o dlroo uaiL+i T=:,:z c'a;'` :�.•.;_t_ .vr yrI Lhcc c c c n t�crsally cc :1:`::- h
caiploycz un�tivV,wc::cts ar x--sJ.im,•r.(GL!
Icgzi ctatuc of an aZuQlo)w uo,,' tha wo ic<'s ocL,m .tioY !.cL
1 undc�ta d th,t a copy of this ctatc:s•r.:ay bo Lo+tiv,ucinJ to tin[Yticvt:.rst:of Indils:rial Aciil.�l:�Chic of i:�ui-�=a for tllc
cove va-Mc-lioa and that C_ilur-to :cC,ic^a5A of MCL,152 can lead to the imposition,�',
coa-lLTTing of a Cur-of up to S 1,iWoo as 'Y it=prisq-:-- : of l:p to cr.-}- e:-.l dvil pc=ltia in a.c fcxtn of+
frW of 5100.00 d day ig�-ina m..
Fcr ti�;utltiztsl uic ally {
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S�CTlON8 CONSTRUCTIONiSERVICES
8.1 Licensed Construction Su 1eerrvis r: t Not Applicable ❑
- 1
Name of License Holder : v Q� G—T]
r 1 1�1 �Vci License Nu her
h c� C Zc�
Address Expiration Date
Signature Telephone
8e ere '.brn m 'r.' vn` Con` fractor.> = Not Applicable ❑
��,�c t��G �i v �►C�' '�. oc�s �,w. �
COMDany Name Registrati n Num e
�LJ1W`
Adc! �_�US Telephone Expiration Date
SEGTIONIO 'WORKERS'COMPENSATION INSURANCE-AFFIDAVIT(M.G: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....... 10" 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 Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION5D'ESC 'PROP 0c`� hek al abRIPTIONIOF lel
r x
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ DemolitionD New Signs [ ] Decks [ ] Siding[ ] Other y]
Brief Description of Proposed Work: fa A IYOQ jyY m 0)- AX kpA
Alteration of existing bedroom Yes_0 No Adding new bedroom Yes �_No
Attached Narrative 0 Renovating unfinished basement Yes V No
Plans Attached Roil 0 • Sheet 0
6aIfNew-1 houseado addi.fion to eXisfin :llousinco.mrp`Ithe w! K:
a. Use of building : One Family Two Family Other Wf G'W w>
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
L 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
SECTI0ht a 1lVNER AU,,,,k MZATION 6'10:13E COMPLETED WHEN
_0WNEk5'AGENT ORCONTRACTOR APPLIES FOR BUILDING PERMIT
z
as Owner of the subject property
hereby authorize +� ` `—j��� to act. on
my behalf, in all matter relative to work authorized by this building permit apphcation.
1
Signature of CWner Date
as Owner/ uthorized Ag
St�f 7�
hereby declare that the statements a d information on the foregoing application are true and accurate, to 1 y
knowledge and belief.
Signed under th p ins and pe alties of perjury.
Print N me
Signature of wner/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 be filled in by
Building Department
Lot Size
Frontage
Setbacks Front Z 0
Side L: �O R: � L: R:
Rear
Building Height $AAAAk
Bldg. Square Footage 7Z %
Open Space Footage %
(Lot area minus bldg&paved
parking) �1
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW _ YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW /` YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT 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:
City of Northampton ;
-_ - - Building Department
pc 212 Main Street,
_ - Room 100
A Northampton, MA 01060F _
06ne 413-587-1240 Fax 413-587-1272 ►t
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This secct�on to be completed by affice
1.1 Property Address:
t,-h 0l U ��Q. Map Lat
Unit
-� Zone
64me-1vVe rtay Distract
AA
Efnt S't.D�str�ct CB,fl�str�ct'
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address: MA- 0 10'04
V Telephone y I �i
Signature 1 ?J� �D 6 ✓ �r°5-7
2.2 Authorized Agent: �
Name Current Mailing Address:
Signature Telephone
SECTION 3-6TIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (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: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-1066
APPLICANT/CONTACT PERSON MARK LANDY
ADDRESS/PHONE P O BOX 61 ASHFIELD (413)628-3203 Q
PROPERTY LOCATION 36 HIGHLAND AVE
MAP 25C PARCEL 189 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
Tvpeof Construction: INSTALL TRIM ON PORCH&POUR FOOTINGS
New Construction
Non Structural interior renovations
Addition to Existin¢
Accessory Structure
Building Plans Included•
Owner/Statement or License 077431
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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 Stree ommission
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.
36 HIGHLAND AVE BP-2004-1066
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C- 189 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-1066
Project# IS-2004-1591
Est. Cost: $1500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MARK LANDY 077431
Lot Size(sg.ft.): 6098.40 Owner: FITZPATRICK ELIZABETH B
Zonin :g URC Applicant: MARK LANDY
AT. 36 HIGHLAND AVE
Applicant Address: Phone: Insurance:
P O BOX 61 (413) 628-3203 ()
ASHFIELDMA01330-0061 ISSUED ON.514104 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL TRIM ON PORCH & POUR FOOTINGS
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 OccuQancy Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 5/4/04 0:00:00 5345 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
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