12C-056 (6) ttAMp
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DEPARTMENT OF BUILDING 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 his/her construction sups.:;;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 roueh 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
U,itpt ��f �Iart I1aIIIPf[III
� 6 fi�assxc}It;srfts � _
M DEPARTmEt�rr Of' EUILDII\'G INSPECTIONS
212 Main Street ' Municipal Building
2\N'orthamhton, Mass. 01060 ' o
wORTCER'S COMPENSATION IIrSURANCF AAFFMAVIT
. D -- -- --
a principal place of busiresslre:�idence t:
do hereby Ccf–di-, un lel- thc p<:}ilS .'.iT7 pCi] ltJe., Chi pC.J�lIIy, illdi-
O I am an employer providing the C011lPCnsauon Coves-'e for Iny
employees wort ing on this job:
(Lnssran� Com anv) e c,Nu abet) ---- �r�. •ir i n Date)
( j I acz a sole proprietor, � (c c!e Oct) nd ha;e hires a o n
the contractors listed beiovv t1i0 i? the `Oi1C Pg -,�10r!KP,2s co%Jper1'3--Ori
(Name of Cor!tnclor) �RS �.7C CGIi:^":7'i nGI]L{ 1t]3Tlb i) T?' •i:tio' D?te)
(Name of Contractor) -- (In um..C° Co an/Po!ic; NLrJb r) iio Date)
(1',lamc of ContTactor) jnS!m c: Cam-l3n.i/Polls-
(Name of Con,rlctcr) — jas, :ta ic- Comr,;_;},rPoticv Numb_*) Date;.
XI tLT1 c; GUlC hl'C3i?i1C Ji i'.P.l ha c no OI:C ',','i;?' iii ' for iT1c.
✓✓� �') �1111 tl home ta`!Il lid?:!, 3T71I't� all i• ilil'' lt.
NOTE.:plcasc Lc at+arc t1:>c.lac tx<rco.i;r 3 a r:. ! ,';:. n i. :rte ',suns a:._r r_m ct:-pat• ..__.._ ct!ir.;
not uK<c th_n throo units in wL-cd; r=-:_:L3 u a; El_,_:._, r er r1 Lhcro e e n_t irz11Y cr :o ti
emPloycz urr_''rt tlx%voci.ces ar -�;a.n Ac,(Gi,152�s 1(5)1.-,:,. ._a;ia;I y a hrmcosu-cr:`cr r hcc e ct p_r::i:r rx
Icgal ctztus of an c vloya undrr t!-,n Wo�c��Col,m utian AcL
I uncle- to d that a copy of t}iu ctatc;s•my bo faw,vciad to t_';o[Ytiuusrsz:of Izdu-riJ- M6r ty O"l°O of 1i="-'r�-a for 11x
covcrnsc vcriLctioc and th_t f.i Urc to a- =c mt-rte;.,u:_lc::cti.io;:25A of?.{GL,152 can It d to tIx impriiia��t c"�in_1 pct:al::u
comistixsg of a fur_of up to S 1_5oC OO-:td'x i^;vi �•,-_:S of::p to en }- r.`.j evil xKmltics in y fc c•rn c(n
fre.OrSIOG.O(l a day
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Fl u.c cr;Jy i
tin tars of i.icy a cJP.tnrttcc. ;
SECTION .... UCTIOM;SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : t 1 u' A S Aa a A j� L) �,7i fC�;�� r>-
License Number
ass 6 fuc eed Rd L,/-) , IL44 ,/1`e/d 0 lv
Address Expirati n Date
Signature Telephone
ontractor Not Applicable ❑
Company Name Registration Number
xnAs fa. ui4yt2 Z) /1 l �
Address Expiratio D to
wed t4;ej Telephone i�3
SECTION 10 WORKERS'C,O,MRENSATION 1NSURANCE:�IFFIDAVIT(MrG: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....... No...... ❑
e 0 :� 'C�ll: �rl .11
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
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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 _
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SECTS.0 15 ESCRIPT ON OF PROPOSED.WORK checkat1
New House ❑ Addition ❑ Replacement Windows Alterations) 0 Roofing ❑
Or Doors1
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other ]
p p L ' rtf �3 �� l2k t C)cji 4;v i
Brief Description of Proposed Work: i 'S i'1�( /� ► � ✓ """ �e1 c h'k/(rw
Alteration of existing bedroom Yes_�No Adding new bedroom Yes X No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet 0
6a>, `flew 44 to 5-,M, ro-,W V'itron.ito76kisfing housing comple e.=fietfiou win:
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
SECTIONI�WNE', N: TO BE COMPLETED WHEN
DWNI:RSAlaEtORCONTRACTORAP;PLIES �FOR BUILDING PERMIT
L- 11� �a �n as Owner of the subject property
hereby authorize _ —j/nmAq Avon)k to ac; or
my behalf, in all matters relative to work authorized by this building permit application.
ignature 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 and penalties of perjury.
Al 1 <` in s f AC I- 1
Print Name
Signature of Owner/Agent Date
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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 a C.
Fronta e
Setbacks Front 1
Side L: _R:—Ll_ L: R:
Rear T
Building Height
Bldg.Square Footage %
Z �
LIL
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 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 f 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:
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City of Northampton � �.
Building Department � a
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE1NFORMA7ION 7
This section tfle,completed by office'
1.1 Property Address: � ��
ke,Wd e, /� Zee pner�ayO�st ct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing�Address:
Telephone
Signature S llil
2.2 Authorized Agent:
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 (a) Building Permit Fee
2. Electrical N,-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 Onl
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2006-0653
APPLICANT/CONTACT PERSON THOMAS AQUADRO
ADDRESS/PHONE 38 LINSEED RD WEST HATFIELD (413)348-4444
PROPERTY LOCATION 16 HAROLD ST
MAP 12C PARCEL 056 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid
Typeof Construction: INSTALL KITCHEN CABINETS SHEETROCK&REPLACE FRONT DOOR
New Construction
Non Structural interior renovations
Addition to Existin¢
Accessory Structure
Building Plans Included• -
Owner/Statement or License 083682
3 sets of Plans/Plot Plan
THE F LOWING 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 Street Co ssion
Signature o uilding 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.
16 HAROLD ST BP-2006-0653
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 12C-056 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0653
Project# JS-2006-0961
Est.Cost: $3700.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THOMAS AQUADRO 083682
Lot Size(sq.ft.): 10802.88 Owner: ZORN MARTHA W&NICHOLAS J KAC
Zoning. URA Applicant: THOMAS AQUADRO
AT. 16 HAROLD ST
Applicant Address: Phone: Insurance:
38 LINSEED RD (413) 348-4444
WEST HATFIELDMA01088 ISSUED ON:1211912005 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL KITCHEN CABINETS, SHEETROCK &
REPLACE FRONT DOOR
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�/p6 House# Foundation:
Driveway Final:
Final; -'/6—D�AeFinal: �4
3�,//04
kvo
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rrp-lo: Oil: Insulation:
Final: Smoke: Final: 01� 0_3/17/06
THIS PERMIT MAY BE REVOKED BY THE Y OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS
Certificate of Occu anc Si nature:
FeeType: Date Paid: Amount:
Building 12/19/2005 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo