25C-224 of Nart4aillptan
� d �tassachnsetfs -
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 i:is/her construction sups.:-t,iSor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be,a one&-tw6-anu 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 your). a rough 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.
Daze
Address of work
location
r
r
Clrf� of .II fl}a111ptoil
i A f .63asaxt}Intrtta'
- =_ —
4. DEPT RTMET-Fr OP BUILDI,\IC INSPECTION'S
212 Alain StrccL • Municipal Building
•e
Northampton, Mass. 01060
«ropdcERIS CoNIPEnSATION GNSUr CE AfT-M AVIT
i
(l,ccns.�'Jpc-rmJttc�)
• ,VILh a principal place of businessIresidence at: ---- -
C'ha 6a -JI7G O C0D(P hone') lJ� '�.1�
(sv�ticit--/M2aClap)
do hereby cerdf;, under the.pzins and penalties of pcTIFY, -hat
F�I am an employer providing die folloWing iworker's comocnsat;o, cove r2�e for in)
l etuplovecs woriong on d is job:
3-3 957a'
H L27/05
Onlur-an= Conrz-z-v) (folic:Nu.—•r) ---pirzvon D i--)
i ( ) I am a sole proprietor, general contractor or homeowner (c cie one) and hzve hired
the concractors listed below who have the folloWmp— workers coi oensadon pakies:
I
(i+flmc Of Contnaor) (In urancc Ccrnoin)'i1'ouc, \Ium*c;) (E-_::)ITau0n D.-Itc)
i
(Namc of Councior) Ons-,uanc ComDaa)•JPolicY Nusnc_r) (EkD- rrtion Date)
JI -
(N.me of Coamcior) (L»u-anc-- Com /PoL Nambu) (Expim6on Datc)
of Contractor
i ()`amc ) (Ibsurancz- Comrztry/PolicY Ntlmb":.r) (Expiration Dar--).
(aG.a. �oc5.l�ca.ilococa.-�•w c�ch ialota�'ion pc�aitias w.11
j O I-am a code-proprietor and bave no one worL-iDg for me.
( ) I am,a home owner perfonulc aLl the work myself.
,
NOTE:pl=c lx twarc tfi*•„a.:Je 6 �arn..•bo employ Pcsoci w cSD c••�—^•-• cs:.e»o c r ,rya work rrs a d..<rt:..`o!
1 ont mote to t�so tmta in tt�ch the bomoowza=rtaido oc oa the p uod_ , tb. %- r-r ox --I!y a cdactii w be
exrployes �'�" C==P :on Aa(GL152z 1(5)�=,-plici6co Iry a bo=co aer fc c lie.-_.or pe=rt=y-46—the
Ic-Sa!nnnra Of=exployer uo&r d2e Wocke-&Co� Aef
[a;adcztaod tha a-On of tbi,ml.cmr a m.y be for-,.ar•6e4 w the f I.odus'.ricl Act&=, OT—or krvr+vw for tLe
aov=rxee vc-'6c:tioo`0 t1t:.t L-ik -c to zc rc'cO% aZ�undG 3.0 ioa 15 A or 1.441-152 m teal to the=p=low of r-:.ni--d P—Min
ooa%i s ora fiat orup to S1}00.00 ar.&IOC i npriloo='==t ofup to ooc y-3 tj)d coil pmattia im tS form ora Stop Wort;Ordc-and a
f=of 5100.00 a d_y t{xic:a t>x
i
Lot '
I=aturr of Lic=i-,ccIPcrTniucc e J
t '
SECTION I-CONSTRUCTION°SERVICES i
8.1 Licensed Construction))Supervisor. Not AApp-licable ❑
Name of License Holder: l_T� �(i(/VI I 4AA 0 /li L/ j
License Number
Address Expiration Date
5� 7 -7
Signature Telephone
ba a >rr ern a , Not Applicable ❑
Company Name Registration Rum r
j�Pr`4-�l �a �� •e��er� c1ta- 1 Ac, c /OFD
Address ,-f r Expiration Date
1 / �� ��YCJl ��iS4'fU Telephone r7 g3
SECTtON 1�-WOIZiCEf2S'COII�IPENSAT110 1INS!]RAi�iCE
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...... ❑
101 ion,
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 1083.5.1.
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-vear period shaII 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
r
SECTION'S5 DESCRIPTION,OF`FROPOSED W6RK(check-atl,�pplicable)
New House [] Addition ❑;: Replacement Windows Alterations) Roofing ❑
Or Doors 25
Accessory Bldg. ❑ Demolition ❑ New Signs [C]] Decks [M Siding[p] Other[d]
Brief Description Qf Proposed F� ` `` r D
WOrk:_,(/eut 5 irlir►cQ_,_ (Vea &- h. ! ea :v 'f!3 c�n� 5&if i imij-F�Cte�t�r;4 L Phl,- L9 (mf-
Alteration of existing bedroom_ Yes No Adding new bedroom Yes No -
d Narrative Renovating unfinished basement Yes No
P ed oll -Sheet
:,. .. �Emr.�'w__. .r +'�'n'rn°y° ,y.._ _.-, =. .;- x...r.. .., ..F'wrm"y.�"`�r.� -.
sa ousn:; rcd�#IO. octsiJncl- ousrragor}mrehefon :
a. Use of building: One family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms „Z P"r L'n1 [-
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? QiL rD%c_A Coy- Fireplaces or Woodstoves 0 Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction _
L Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain l Yes No
j. Depth of basement or cellar floor below finished grade J
k. Will building conform to the Building and Zoning regulations? _ Yes No.
1. Septic Tank City Sewer_ Private well City water Supply
SECTJON 7a OV11N(;R At7T{3O.R12ATION-708E COMPLETEDilIHEN
OWNERS AGENTi�QRtrONT#2AGTOR�PPLIES OR 61�1CDING PERMIT;"
A` d lei
I, t C l� Q d 1 ,as Owner of the subject
property (/
t"t
hereby authorize .rf-� Q!1
to act on my behalf,i a matte reldtiZ to work auth rized by this building permit application.
Signoture o wrier Date
1, �( (� ,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.
i
Print Name
s nature of O Agent Date
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
-7 Q a Building Deparunent
Lot Size
Frontage
`]
Setbacks Front �•j �C5
E��' l� •V
Side L._1 S" ; R:` �T LJ L R:I
Rear �^ �— ?A
Building Height
Bldg.Square Footage {—I
Open Space Footage �_ %
(Lot area minus bldg&paved
parking),
##of Parking Spaces
Fill: i
i
(volume'&Location)
A. Has a Special Perm it/Varia nce/Fi nd in ever been issued for/on the site?
NO 0 DONT KNOW YES
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page' and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES i
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 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:
E. Will the construction activity disturb(clearing,grading,ex0avation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 r NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
N ty of Northampton
C y uilding Department
4
A.12 Main Street
3 �C05 Room 100 k
v Borth mpton; MA 01060
hone 41`3-58 -1240 Fax 413-587-1272
p - x
^.S A.
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
'SECTION:1 SITEsINFOFZNlATION"
� � �'"�,�� ,� �t»s-sect�an to iJe cotnpleted"b�raffi�e
4y T "'. y
2 owe Ouerla istncfr
SECTION 2 PRORERTY QWNERSHIPIAUTHO.RIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing A dre s:
Telephone '
Signa re
2.2 Authorized Agent:
O Clj4 V-d, � 1- 605 19
Name(Print) Current Mailing Address: C j �
1
Sig ature G Telephone
SECTIONS .EST{M(47ED-�GONSTRUtTION'C 05T5
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 0 (a)`Building Perriiit Fee
qO OV .
2. Electrical bmtalCost o 1-1:.Construdtion from 6
3. Plumbing .BUilding Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=0 +2+3+4+5} Check-Number
:This"Section Fo�'Official'Use On1
Bull lding-Permit Number =issued:
Signature: r
Building iCommissioner/Inspector oUBuildings Date
File#BP-2005-0759
APPLICANT/CONTACT PERSON KEITH HAMILTON
ADDRESS/PHONE 3 LORD ST EASTHAMPTON (413)222-6463 Q
PROPERTY LOCATION 60 WALNUT ST
MAP 25C PARCEL 224 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out �n n
Fee Paid
T_ypeof Construction:_RENOVATIONS TO CONVERT 2-3 FAMILY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 074129
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PYESENTED:
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
6. 2
ZONING BOARD PERMIT REQUIRED UNDER: § �7—$'l L�
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 Stre omrnission
Z /O z0
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.
�� bpd�6� .4I GtV r6h �/°76 ryiY/
avc
IVY
AZ
c,oj ���'
t
60 WALNUT ST BP-2005-0759
GIS#: COMMONWEALTH OF MASSACHUSETTS
MU:Block: 25C-224 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0759
Project# IS-2005-1061
Est. Cost: $90000.00
Fee: $450.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KEITH HAMILTON 074129
Lot Size(sa. ft.): 6969.60 Owner: PODOLAK JAMES L
Z.onine: URC Applicant: KEITH HAMILTON
----—- --
AT.- 60 WALK i i i ST
Applicant Address: Phone: Insurance:
3 LORD ST (413) 222-6463 0
EASTHAMPTONMA01027 ISSUED ON:314105 0:00:00
TO PERFORM THE FOLLOWING WORK.INTERIOR RENOVATIONS 2 FAMILY
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service:3�r/b Meter:
Footings:
Rough -'���� ought (, House# Foundationi�!/,,G(y
y/zays--�F Driveway Final:
Final:811 (� 'L�J Final:�/�����j=- 6 ��o�'L176
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:Ok
Final: Smoke: `�j g�a � Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT ON OF
ANY OF ITS RULES AND REGULATIONS. Of
Certificate of Occu anc Si nature:
FeeType• Date Paid:_ Amount:
Building 3/4/05 0:00:00 $450.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo