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� � �lassachusette
t
m 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 has/her construction sups::isor. 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 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
understand the above.
/resi re
( e ow r ent's signature reques g exemption)
I wi call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location t C trO�–t—`Jf
4--7(o tnncl� A
���UN hTO
' � f✓� y
$ 6 JRIK 77RC 11 tit;ctl a -
m DEPfiRTT ENF-f OF £UILDNG INSPECTIONS
212 Train Street ' Municipal Building
Northampton, Mass. 01060
NVORICERtS COMTE.NSA'nON INSURANCE AYFID VIT
principal place, of busincssJr _;i�enc t'.
CIO hcrcby cc!-u!y, a tits- d)1 ' p2illS 2iiCl pC i] 1t7eS Oi pC.I�llty, iIlllt.
( ) I am an employer providing t11e follo.:;n %V01,r_cr's cotnpcns Uon 1,01 lily
tillployces \VOI dng oIl ahl1 )ob.
J='L CG Compam-) Pc-c:Nu:nbcr) — "rte pir lion Date)
I awl a sole proprietor, genPrai cen=ac`or f_--4_ec:ccwoerlcicle one) and tlave 'tiired
tale contractors listed beiov ": o 1:� ,1Y1m`ol ,:;Q, rs coi!pen_�:'_lon
(_N c of COritr:lctor) (Insa�.-n cc Cc:nn':)T,P(D1ic•1 NIurnlvr) I x-Z i rnucn Datc)
(Name of Contr cto:) (iltsl ;ne Comna.nvPo!ic; Nt i�rr r) (1 `: .atin Dzte)
(Name of Contractor) (Ins nee Co ;;;;zn.;i?olic Nuys ht r) s;.°r::do Date)
-
'Na of Contnctcr) — (IDSZ rand COiP.? ,}' P G1iC 1ti1umYi r)
1 <L Il <'. Ole 1?l Ol?r1LtJi 211:1 it ?'',' 110 0I1L
2111 a home OW?l tiC. C`Ii11I1„ :(( i_.
NO'I1i:plcasc t.nw•1rc t!s:-.tip i)c tr:�nco�t:r_r.u;-�r._.�!�;,r,.-��:.�::�:-�_-�,�.�c�cz:.:::n��m cr:-��ait�c•,;;:...._�«clii-�,
noe mere tlL:n tluco l:ui�ir,t�i:ul t!�e lti,.-.�.•.lir�r`.:<:;�u a;'`�.-t;:�_:.:3 z �:r:ct:_.r1 Lhcetc a�tx:(ecrt�l!y ccr::::::::::�tv
cV'ployc�u_•',cs tlr wcr?•x:'s cc -�:_icr.P.C:((3:.152.»!t5}!,--t:, ._;:ic;:%y a F.n:amu�lcr`cr a Lc-z'c ct I:::....._
1oS11 statue of an e=pto)x under LLC wor�els C-CxL" _ 6t n:`.cL
!w•�dc.-stand thL a copy of th:i ctat—:-s_•cuy bo fo,Ivti�j to tIx fYS>ortz ,:of Ln riJ Ac66�_y Cf:l�of for llm
my"E�c va ifiiCtioc aid Ih:t f ltuc to r c co�^`r ut. zccicr_?SA of MCI,151 can lc--d to the iriTI-',�sitio-3,�t c z--*--i.:1 pcc:al:_u
comisting of a fur_of up to S 1•SLk OQ art.'x i^:;lr r.�1; of;:p to cr.--}u r.:.1 civil,cmlticz in do form cf a S!c;,' `nx Orx"and a
f s�oC S 146.00 a day s g:61ra m-.
Fcr dcT:ut: :al u,c lly
5€CTQN 8 CONSTR'UCTIQN SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
-" «" -"mow.""". r Not Applicable ❑
Reg"sere `ome lifraroiremenYContradtor-
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS' CQMPENSATION 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........ ❑ No...... ❑
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.
-&omeowner Signature
ri WSP �
SEC7IOfJ :a�D1=SCR�TJ0N10P PROPOSED NVORK check all a lica�le
,..
,,.gym
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other ( (
i
Brief DescriQtion of Proposed Work: / f"o
Alteration of existing bedroom Yes -No Adding new bedroom Yes __IZNo • �
Attached Narrative❑ Renovating unfinished basement Yes ENO
Plans Attached Roll❑ - Sheet❑
6a1.ff�te'w�hous"a ndor°addition/to eXisting"housing;comp`le e�thefoiLowing:
a. Use of building : One Family t/ Two Family Other
b. Number of rooms in each family unit:, _ Number of Bathrooms .i
c. Is there a garage attached?
d. Proposed Square footage of new construction. �Ce Dim nsions
e. Number of stories?
07 6Lbayea� �d
f. Method of heating? CPr'15 (0 6T; e Fireplaces r Weeelste ee / Number of each a 7►r7WI�C5
g. Energy Conservation Compliance. Sp Mascheck Energy Compliance form attached?
h. Type of construction CC(,0101 ftt-
i. Is construction within.100 ft. of wetlands? Yes �No. Is construction within 11000�y.,r floodplain (_ Yes],�No
j. Depth of basement or cellar floor below finished grade t=t�� �CC-5&M 1�/✓1�-�u Iaou- / e3hf(l
k. Will building conform to the Building and Zoning regulations? V Yes No .
1. Septic Tank City Sewer Private well City water Supply
SECTION7a GINNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT�OR�CONTRACTOR.". PPLfES FORBUILDING PERMIT
I, as Owner of the subject property
hereby authorize to ac;. 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 forelJoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Nam / r `
Signat Owner t 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 dll kd d/1'?d_ j
Frontage
l71 �g
Setbacks Front 7
�
Side L: R: L: dV '/R:30 /�--
Rear
Building Height
Bldg.Square Foot %
C;.
Open Space Footage %
(Lot area minus bldg&paved
-parking)//
#of Parking Spaces l0
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO V DON'T 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:
J
071 P-61
�f Northampton
i in Department ;
r- Main Street
!4' "004 oom 100 ��k
L': JUN No pton, MA 01060 ►s
r
i phone 413 587- 240 Fax 413-587-1272 P .
. ,
BU!lDl"cGtt�SFtCT0S
LAPP& O CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-'SITE INFORMATION
Th�ssect�on to be completed by oifr
1.1 Property Address:
r s MaR ' tat Unit
1 1 1 tl �'l((� —��' F Zone L r Overlay YDistnct
Zjp
---r .
EImSt D�straict ;'CB D�stnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print Current Mailing Addre . 11�
4LJ
Telephone
Signatur
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 (� (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 l� ^
This Section For Official Use Only
Building Permit Number Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-1279
APPLICANT/CONTACT PERSON DONNELLY TERRENCE P&GAIL K
ADDRESS/PHONE 107 HILLCREST DR FLORENCE ��
PROPERTY LOCATION 107 HILLCREST DR '1
MAP 17A PARCEL 303 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: INSTALL ABOVE GROUND POOL W/DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN/FOMATION PRESENTED:
Y 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 C ssion
11-71 Zoo
Signature of Building fficial 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.
107 HILLCREST DR BP-2004-1279
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-303 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-2004-1279
Project# IS-2004-1929
Est. Cost: $5135.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 21.823.56 Owner: DONNELLY TERRENCE P&GAIL K
Zoning:URA Applicant: DONNELLY TERRENCE P & GAIL K
AT: 107 HILLCREST DR
Applicant Address: Phone: Insurance:
107 HILLCREST DR 0586-24600
FLORENCEMA01062 ISSUED ON:711104 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL ABOVE GROUND POOL W/DECK
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: /� 4-K 7 ,C
Rough: Rough: House# Foundation:l7 OGs L�(
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:6)A— `7- 2G.p t�/ _
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA T OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy,_ /0��e_Sipnature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 7/1/04 0:00:00 2929 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo