17A-059 (2) �Q„'StfAMP�O c
tie Crztly of Wort4amvton z
$ � �Giaasxcl�usctfe
lsi 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 iris/her construction sup(.,.,-,,,: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
'� a �1-zip,; z�f �ctz-tlJ�tllt}�fctlt _ �.
� - e �+I=sanrt,nscct�
m DEPI-JRTMENFF Of' LUILDRI G INSPECTIONS
212 Main Street ' Municipal building
Northampton, i fass. 01060
WORICZR'S CO' TI'ENSATION INSURANCE /_FFUMNI.T
\:pith a principal place of busiress/resdenc
do hercI)y CCI–L1Ij', llllacr dlc p ins anc pC it 1tiCS OI npt;,�llrv, 1_1M*,.
(V�I am an employer providing the ollov;ML: •.orr_crs colrinensauon covert: e or my
emplovees working on dim job:
(InsrranG Co �') i c:ic:?r`urn[xr) ('r�;rir,:aea Date)
l j I act a sole proprietor, general co-, =Of o- rlorn,cowoer (c:.rcle one) and 't-:ave 'dirt d
t.h, coiluactOfs listed be.o\'v ill: `Oil vjoFkPrs CO%1D°n-a--orl —1iC:es:
(Taitnc of Contactor) (InsU-ncc Conc--i-!Tolicy NusntYr) rat;ca Datc)
(Name of ConLr c or) -- ti lsJr,rce Comn_r:`/Po!ic' Ntnt r) atio Date)
(Name of Contractor) ([n s1c� Co ;_ !;iPolic, i�uli tr r) - -xi: r c,D Date)
_. (Name of Contractor) -- (I11S1 E-al, Coa,7 y!Polir--y tvtumi;�*) - (Fi:ri-::ior Dace)
(atL,Gt:.d-±lhcc:al S(:CGt:_..__._. :O ..._.,.0.....'K':].1..,,v ,.-._.... � •.L J:G:._......'
C 1 <LIl <t OlC prOj? 1C li Sill it ?�' il0 Op',
c�
—Mil-, all t!.
NOTE:picric be awa:c tits,-.c ilc
not tnete than(lute units in%%i--di c>i cx; txt�cxsallY a :=
C=ployv-3 U.-6cr t}Y tvcr}: s a�x-_:eti s,r.((ri.!52�a!(SQ,r:;._a;ia:try a hnr, o« w for z Lccu ct
legal etatus of an cmployx under tl:a Wo,ic,'t o .Iion!.cL
I un6c_-T-.nd thi a copy of O},x ctatc-,----:cuy ho to tl�fY.tinrtxrszt of Indutric!Ater-ms s'(DiFao of i:::+-,r 7_a for tix
oovaxgc vai[ctioo and that f_iiurr to rn :001--r_g-o urd::4,:Uo-a 25A of MOL 152 can Ic_d to tlx irntOsition of crm i:_1 pasl::.%
comisting of a fim,of up to mz`a'Y i^nrisr,z�.,of;:p to cn:)-,Z:�:.j avil),-Mltia in Itmn C.f.,Sir)` 'nY,OnI=tnd 1
f ac of S 1 P).W a dty
\ rcr dcv; 1 'atsl u.c uily
Lot
Ji vacate ( T i.iccn:cJl'r_rm;;t _ _ _-_r ;_ F
11 oil
S�CTON 8=CONSTRUCTION SERVICES
8.1 Licensed Construction
--Supervisor: Not Applicable ❑
Name of License Holder
License Number
A s Expiration Date
u.
Signature Telephone
Reg s ere �'`orne and•o�emerit Cont actor ` Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SEGTION 10 WORKERS',COMPENSATION IN (M.G:L. c. 152,§ 25C(6))
- � ,..e_
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 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,v_ ou 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
f- ^•
SECTIONMS D SCR.PTIONOFPROPOSED WORK[check alt apnlicale)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ) Other [ ]
Brief Description of Proposed Work: �M� � `Z���'�1'� ��"��� (`�, � •p , � �_ L
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
sa :fNernuse ndor a:ddi#ion to.existing housingcoetetiefIlow.rne•
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
-SECTIOT[7aOYVNER AU�t10RIZATJON "TO BE COMPLETED WHEN
OWIVEkSAGEtTOR CONTRACTOR APPLIES FOR BURDING,PERMIT
as Owner of the subject property
hereby authorize to ac; on
my behalf, in a I matters relative to work authorized by this Building permit application.
� L
Signature of Owner Date
�- a -�► /.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 undg,the pains and penalties of perjury.
Prin e
Signature of Owner/Agent 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 j
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Buildin g Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Spe ial 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 � 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. L7Aere any proposed changes to or additions of signs intended for the property?YES_
No
IF YES, describe size, type and location:
r
City of Northampton
Building Department t
212 Main Street
Room 100 `
Northampton, MA 01060 r
hone 413-587-1240 Fax 413-587-1272 OE
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A O &A?FLj DTfEWNR.::�
'i L AUG — 4 200; i a
SECTION 1-SITE INFORMATION; i
Thrs sect,o ,to b
1.1 Property Address:
y, 5
�ZQne�F q.5 x.t° b OVerIaY IQ`i5tnct
Etm
'Di �. G6 b�sfrrct
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED-AGENT
2.1 Owner of Record: �p
Name( int) Cu rr Mailin Address:
v,rr 0 eti � ��. 1 �
Telephone
Signature
2.2 Authorized Agent: \
a (Print) Current Mai mg Address:
�> =nc::� �� \2�4
nature I 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
This Section For Official Use,Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
204 NORTH MAPLE ST BP-2005-0153
GIS#: COMMONWEALTH OF MASSACHUSETTS
Xv;DjQck: 17A-059 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-2005-0153
Project# JS-2005-0168
Est. Cost: $5000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: CDT CONSTRUCTION 130152
Lot Size(sa. ft.): 7230.96 Owner: MCCARTHY CHARLES E III&KATHY
Zoning.URB Applicant: CDT CONSTRUCTION
AT. 204 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
158 NORTH MAPLE ST (4131585-8677 Workers
Compensation
FLORENCEMA01062 ISSUED ON:8111104 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 Occupang si nature:
Feel e: Receipt No: Date Paid: Check No: Amount:
Building 8/11/04 0:00:00 5994 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
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10. Do any signs exist on the property? YES NO
IF YES, describe size, type and location:
Are there any proposed changes to or additions of signs intended for the property? YES-NO V,
IF YES describe type and location:
11 YES, UGS".rl e size, �r�.
11. Will the construction activity disturb (clearing, grading, excavation, or fillip ) ver 1 acr or is it part of a common
plan of development that will disturb over 1 acre? YES NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO'LACK OF INFORMATION
This column reserved
for use by the Building
Department
EXISTING PROPOSED REQUIRED By
:ZONING
Lot Size
Frontage
Setbacks Front
Side L• R: L: R: L: R:
Rear
Building Height
i
Building Square Footage
%Open Space: (lot area
minus building & paved
parking
#of Parkin- Spaces I I'
#of Loading Docks
Fill:
(volume & location)
13. Certification: I hereby certify that the information contained in is true and accurate to the best of
my knowledge.
Date: "( Applicant's Signature
NOTE: Issuance of a zoning permit does not relieve an applicant's burden to comply with all zoning
requirements and obtain all required permits from the Board of Health, Conservation Commission,
Historic and Architectural Boards,Department of Public Works and other applicable permit granting
authorities.
W:\Documents\FOF-i\4S\original\Building-Inspectoe2oning-Permit-Application-passive.doc 8/4/2004
File No. e
FF--. ZONING .H'E'RMIT APPLICA TION 010.2)
Please type or print all information and return this form to the Building
Inspector's Office with the $15 filing fee (check or money order)payable to the
City of Northampton
1. Name of Applicant: l, UI{4 2 L C t2-
Address: a 1 4 �V ��1� b���L j Telephone: S L"la 5 f � Z
2. Owner of Property: C 4-- G✓t. (f
Address: W V--t t,4 4 L_ (�5 ) Telephone:
3. Status of Applicant: Owner L� Contract Purchaser Lessee Other (explain)
4. Job Location: 2 c'(4 '�'
Parcel d _Zortmg flap#' Parce}# - DtArtct(s)
- - � }ra E}rra Street Dtsinct i - In Central Busrness Dtstrict - -
. .�
5. Existing Use of Structure/Property: F`�U lki -z-
6. Description of Prpposed Use/Work/Project/ ccuppation: Use additional sheets if necessary):
7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans
s{. Has a Special Permit/Variance/Finding ever been issued for/or. 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#
9.Does the site contain a brook, body of water or wetlands? NO 'N�< _ 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:
(Form Continues On Other Side)
W:\Documents\FORMS\original\Building-lnspectoeZoning-Permit-Application-passive.doc 8/4/2004
File#MP-2007-0040
APPLICANT/CONTACT PERSON MCCARTHY CHARLES E III
ADDRESS/PHONE 204 NORTH MAPLE ST (413)586-5712 Q
PROPERTY LOCATION 204 NORTH MAPLE ST
MAP 17A PARCEL 059 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
ee Pai
Building Permit Filled out
Fee Paid
T_ypeof Construction: ZPA-RELOCATE DRIVEWAY
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 FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
pproved 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 Com� OF /
/,
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 the Office of
Planning&Development for more information.