17A-207 (9) s
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060 s
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 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.
Date
Address of work
location
{
$ - 6 kialsR(fill f;r 5
DEPfu'tI'MENr OE' BUILDING INSPECTIONS
212 Alain Street ' Municipal Building
Northampton, Afars. 01060
WORICER'S COMI TENT SATION MSUIZANCT A.FFD)AVI.T
v"I'Li] a principal place of bi- iresslrc:iidenc, a t:
- ` -
dD l]CI"CUy' Mldf);. un;' 1" d]" D—TI_°, ::ilk pC i131 ICS C)i C:r�lll�f iS:I+-I.
am art employer providill- the follov;iI': '::Ut"r;CI'S coil]1]CI]sau0I] GOVCf2�,C for Irly
loyces wolidrig on t?Iis job:
(Las-,L=a; Cock e ,•) C;ic, 't nnber) ----- r�> r,:ion Dace)
( j I am a sole proprietor, enerai c-�n'Lrc:or nonleowoer (circle one) and, h ve hired
td
conC.L•actaCs hsted below t'a + - C, r •- o pciil,
:�0 1:-•�.-; �h . o ��-:��r ���or�ce s cot:. p n��orl ;.:�.�,,.es:
(NI=p- Of Conti ao 11su7aIl nn` 'm -
r) � cc C oI :;t,. cticf NulntYr) ,, • ?c-; Datc)
(Name of Coi2ncior) y 11LS� P.CO C0 ;i�'/PO ICi 1 Z7)i'_'r i m.ti o:,.dale)
(N''ame of Contractor I _ .;_--.._ D
) � IU...,,I1C: �_:�iL l:Of;C� I�ilJi]}'f�7) �. _\< i:i:0D aIcj
- (Name,of COIlirlctcr) -- (IaS raI1Cz- CoII?t Y; l OLSCJ �IIIRl�r S} (_T::u`. :iS� ?tC)
1, 1 i�III < 5olC 1?(Ujlr1C'�Ui 2iIQ Ilt:Ve i�0 O1? l;r��;i:ih foi- -m t.
(, Pill < honk (v,!Tlt 1�1 i?.
IY:
?'IO-I-f::picric be nw: c tl:sr., ilc =P!ay;r_ It;_t -•:ancc v ccn m Cr:-pat vi;c.._
not lrKvc th_a throe uniu in Mzc�r�x f r. .:iz, r=: �cr cx;'` _,-.'_z z ur ct 1 LhGGO:c n<�cr1:11}'a h
czl;)'oycl u-•-A. tlx -a At.(GL15?ss!(5)),ap f:Gcc3c ct p-z;:ic cr�c C_-
lcgzl rtaSur of rn a=ployx unc'e,-V:C Wa car oa,xr.lion .ct
I undcYland thr a copy of oia c21tci cr•r_iy Fo l01',V trl to L o IYt a Lz,sz of Iru4uriJ Pt zl�1�Cif o of!: ,raax for tix
coverage vaific--doa artd that f.i Urc to -^err co�-r ero uc cC,ir 25A of MGL,152 can lc--d to the inrpozitio�,f r ir.1 pa sl:u
cocr_isti g of n fur_ofup to 51.5y).00 ft:1r-'c'r i7,-, rz c:1 of::p to cr.-} n.-.1 civil pern.1/icz in!,ionn of a stc--,`:vnY }vim.nd a
f:m of:;I 00.W I diy ag2iaa m_
For dli:utll—enl u. ri:Iy i
Permit Numtx -- --
511;11aturc of i.iccn cJI'unr,u
SUCT10N 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Add r s Expiration Date
p
Signature Telephone
f9Regsier"ed�o�rrror"o�rerneritContracto �� .. r Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECT ERS' COMPENSATION 11NSURANCE=AFFI DAVIT(MG.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)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 acccptable 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 _
SECTIO1�f =D 5°hRIPT1.0iN OFiPROPOSED WORK check llra lacabie
aa:..,.,,r..•:,. Wc '..;
.:.rix x'-.z', r,-., S �"xa,».z;,,°�^i .n, ,p =�n .,,.'�,,.:;:: _ .i:'" ..
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ .
Or Doors M
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other
Brief Description of Proposed
yV yJ
Alteration of existing bedroom Yes Y No Adding new bedroom Yes ✓ No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll O•Sheet 0
bat �_e- o s nd oradditi:on�to�ezisting-housi`ng�completTiefoll'owin�:
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 .
f. Septic Tank City Sewer Private well City water Supply
SECTI�dI� OWNERAIJTHORIZATION TO'BE COMPLETED WHEN
R?'APPLIES,.EOR BUI�.DItVG PERMIT
1. as Owner of the subject property
hereby authorize to act. on
my be h a a ers y t' e work authorized by this building permit application.
/—,2&---0
Signature of Owner Date
��J4
I. 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 pa' s and penalties of perjury.
Pri me
Signature of Owner ent 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
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 \/ 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#
V
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 Issu
C. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
D. Ar re any proposed changes to or additions of signs intended for the property?YES—
No
IF YES, describe size, type and location:
SO
City of Northampton
Building Department
212 Main Street
JAN 2 1 T04 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 SITE INFORMATION
Thrs secfio tQ be completed by oWce
1.1 ProneLt Address: w ,
vi
m �
uerla�`113 C
m
qm-St.Distract _"` '�5 _ _:CB District _ -
SECTION 2-`PROPERTY OWNERSHIP-1AUTHORIZED.AGENT
2.1 Owner of Record: --�-
�� G a e--(- I
Name Curre i�ddress:
-7 Telephone
Signature
2.2 Authorized Agent:
N A(Pri Current Mailing Add ess:
Signature Cj U 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) 4::::Z; a Check Number / d
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-0758
APPLICANT/CONTACT PERSON CDT CONSTRUCTION ./,C "— 6 a 4 —3
ADDRESS/PHONE 158 NORTH MAPLE ST FLORENCE (413) 585-8677
PROPERTY LOCATION 131 NORTH MAPLE ST
MAP 17A PARCEL 207 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildin Permit Filled out
Fee Paid .57/ ,5
T_ypeof Construction: REPLACE 3 WINDOWS,PATIO DOOR, SHEETROCK&MOVE NON-BEARING
WALL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 003666
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9V64ATION 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
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.
131 NORTH MAPLE ST BP-2004-0758
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-207 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Cateorv: BUILDING PERMIT
Permit# BP-2004-0758
Project# IS-2004-1108
Est. Cost: $8700.00
Fee: $50.00 P RMISSIONIS HEREBY GRANTED TO:
Const. Class: Cv tractor: License:
Use Group: CLT CONSTRUCTION 003666
Lot Size(sq. ft.): 49222.80 Owner: WALDER MARTIN J&JOAN
Zoning: URB AIr:licant: CDT CONSTRUCTION
A_7': 131 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
158 NORTH MAPLE ST (413) 585-8677 Workers
Compensation
FLORENCEMA01062 LS.SUED ON.1123104 0:00:00
TO PERFORM THE FOLLY.`VING WORK:REPLACE 3 WINDOWS, PATIO DOOR,
SHEETROCK& MOVE NON-BEARII G WALL
POST THIS CARD SO IT IS VISI 'E FROM THE STREET
Inspector of Plumbing Inspector of icing D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Departs t Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVO, 1 BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REG C . „kTIONS.
Certificate of Occupancy Signature:
FeeType: Receipt No„ Date Paid: Check No: Amount:
Building 1/23/04 0:00:00 5718 $50.00
212 IVi:; . Sueet,Phone(413)587-1240,Fax: (413)587-1272
3uilding Commissioner-Anthony Patillo