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David . Westcott
Z ALLEN GOIT ROAD
HUNTINGTON MA.01050
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rs DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building '
Northampton,MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction supe:.,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 hour), 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.
(Rome 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
��tt/N ff
�0 fib -
Oldtl�y of Naz-ffla1 Atoll
6 �:l�i SS ACiI Ii5CII3 =
DEI>A.RT1.1EArr of DUILDING INSPL-=IoNs
212 Main Street ' Municipal Building;
h'orthainpton, Mass. 01060
WORKER'S COMTENSATION INSURANCE A-F D-)AN7 T
1,
%with a principal place of businesslr(nidcnc
------ ----- —---------- --------------- -- —--(p ho n c
ISLrc-- c7 p)
do hereby Ccr—dII'. lllla " die l)%ii1S ?.ii7 pCil 1t1C;; Ui 7CrJllf� t.Iliai
O I art, ��rl employer providing the follo`,,'int •:orr_crls COlnpetlSaU011 covel<:gc for my
employees working on t?lis job:
(1=,L c- Company) (Pclic;Nll�abcr) ---- (Ex-pimdon Date)
l I anz a sole prooriet_or, general conk or onleot,�ner ,c c!e one) and have tvret
the contractors Lsted below„ho it the `oiic ? worite;s corlDen on nuci !--,S:
Aw'i al
(I`amc of�OnLI 1CtG:) (IASd'�t1C LvI ^?:7'tr�GhCf NL11I1CCi) ?'t DiatC)-
1�-
(Name of Connctor) -- (Inscr,rce Come:
iv/Pc-!'c} N=bcr, (I xp:ratiGa Date)
(Name of Contractor) (Iv s>ce Co an;;i1'olic: i�uJr_rr r) (=x. :�tio- Date)
- (Name of Contractcr) - (Ins ranc< CGtnr Y,yrPoli� Nu.mh�*) - (E x :-aio- Date)
nil
J
C I <LTl it stile It"U )tICCUi c:i11 I1L?v
il0 r
l- l OI ., • 'l. :;�il 10r
(; I aln t1 home UW?1C. i)Ci:C
*�0"�:.plC.--SL t�C tll\•7rC L:S:•.11:`IC Lrf!i.CJ\41 Y_;}11�.',c. p1;ry iY`����„1.�\���:_1[SC�CZi.:::7-��iYl G(::ii1II t\'t;�...n_l\\LII::=.'�C.
not UKCC th--n[loco unii ir:ut_d+i he f:;1�;.\rr rc_: a a a.` �.•;:_}_r.,r c_r1 Lhcdc e [t{�crrtal}Y c,:r::::::: :o h
employe u-"^ t}x:vca,�s cc •�:nti.n Pt.(G1,152..-z1(S)l,atpi:r..:ic::by a hMaco\w`or t Lccx cc p:ra:i:: tir c tr_
ICS21 etatue of nn amployer uod' tLn worl;cic Coz`;w Zion'x'L
I underzt.ad tL,t a copy of th-a ctst*clay bo Igwnrdol to tl' IY.t nrLlKit of Indu lrt_1 Aa3l•njy OfrjM of for tlx
coverage VtrUiic:iioa and the[L•ilttrt to: z:CO'ut 3: c�.ica 25.A of MGl,152 can iui to the-impositiol of r—' .i pail:a
e'oatisiing ota fur_of up to S I.S0U.o0 of::a to cr.:)-,Zr e-.j civil xrzltia in do icn:l of n Str,,`;\'ni.(}�;�n:A
frr-oCS100.00 a<d.ty agl-in:.t m; .
----------
'_� For Sq:uhmCil u.c cn7y i
Pcrrnit Nuuitr.:.r
C----
;,,-__ .,. trvaturc t�f i.iccn�;ctJI'crnr,;tr.� _ -T-;i�=•�-�- I �
SECTION 8 'CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Reg s e e brn rxrprovern'ent ont`racfo Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SEGTIOIR 10 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....... ❑ No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)fami.ies
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
SE�CTf0N5. S. R FT�ONOPROPOSEQINORK check�al a livable
.:
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding[ Other [ ]
Brief Description of Proposed Work: '6")C.lps•e 4?-l5 4-)+3n Uo�orc-� !�i>fd � ��r�i m_ Sc.Ypr� Pan Q S
(Cqe door)
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 • Sheet 0
fa � ::ever :ou e tl :��tltl,�tion to ezisting�h uo sing` compt�e.•et�"e�fioCl.ow�:n�
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 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_
SECTO WNERAUFIORIZATJQN TO BE COMPLETED WHEN
h
OHYNEE& ENTO�CONTRACTORAPPLIES FOR BUILDR PERMIT F
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/ uthorized Agent
hereby, eclare that the statements and information on the foregoing application are true and a the best of my
knowkfte and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of wne Agent Date
t
f
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INF0RMA.TI0N
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot ze
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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
- - -T�Bu`+ Ti�►g Department
2 Main Street
;room 100
�n ort�ha� ipton, MA 01060 e
NOV
phone 13.587- 1240 Fax 413-587-1272 t
APPLICATION%,Tt)'66 STRUC�, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION-1 - SITE.11N,FORIVIXTION
1.1 Property Address-' * a
ax Ms' s .
@4 x.
�^ I
1'51-0✓ °I ,Ovrlay Dastr ct.' �
EIm,St District ' -Mr-0; .CB s r ct :.
SECTION 2 - PROPERTY.OWN R:SH P/AUTHORIZED AGENT
2.1 Owner of Record:
J by L4 �7 /�n��v� i4 S
Name(Print) Current Mailing Awrrs:
f`�D�'�P►? P �" /D 6 v
� Telephone � � �j
Signature ' L -
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTI0N..3.- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be official Use'Only
completed by ermit applicant
1. Building Qom- (a) Building Permit Fee
2. Elec.rical J I (b) F timated Total Cost of
o '1 Construction from; 6
3. Plumbing j� Building Permit Fee
4- Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5) Check Number dS�
s This Section For Official Use Only
Building Permit"Number: Date Issued:
Signature: _
Building Commissioner/Inspector"of Buildings Date
File#BP-2004-0574
APPLICANT/CONTACT PERSON SECTOR JOHN C&DOROTHY C
ADDRESS/PHONE 17 MOUNTAIN ST (413)584-3718 Q
PROPERTY LOCATION 17 MOUNTAIN ST
MAP 17A PARCEL 073 001 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: ENCLOSE EXISTING PORCH W/STORM&SCREEN PANELS&DOOR
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORkATION 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 C ssion
C%rt/ Zf�
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.
17 MOUNTAIN ST BP-2004-0574
GIs#: COMMONWEALTH OF MASSACHUSETTS
,tvtd - 7 .U73 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0574
Project# JS-2004-0804
Est.Cost: $5600.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 11456.28 Owner: SECTOR JOHN C&DOROTHY C
Zoning:URA Applicant: SECTOR JOHN C & DOROTHY C
AT. 17 MOUNTAIN ST
Applicant Address: Phone: Insurance:
17 MOUNTAIN ST (413) 584-3718 O
FLORENCEMA01062 ISSUED ON:11 110103 0:00.00
TO PERFORM THE FOLLOWING WORK.-ENCLOSE EXISTING PORCH W/STORM & SCREEN
PANELS & 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# 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 Sienature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 11/10/03 0:00:00 916 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo