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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The Stat of Massachusetts allows the homeowner the right and�78 0 CMR 108.3.4 to
act as has er construction sup,-,: ,isor. The state defines I caner" as, " Person(s)
who owns parcel on which he/she resides or intends to be, one or two family
dwelling, a ached or detached structures accessory to suc use and/or farm structures. A
person who onstructs more than one home in a two-ye period shall not be considered a
home owner.'
The building de rtment for the City of Northam n wants any person(-)who seek to
use the home own r exemption, to act as their o construction supervisor, to be aware
that by doing so yo become responsible for mpliance with state building codes
and regulations. Th inspection process req res that the building department be called
to inspect work at vari us stages, which inc de foundation/footings (before backfill),
sonotube holes before our a rou h b ildin ins ection before work is
concealed insulation in ection if re uired and a final buildiniz inspection. The
building department require these ins ctions before the work is concealed, failure to
secure these ins ection- can suit ' failure to obtain a certificate of occupancy
until the work can be 7head
If the homeowner hires to perform work(electrical, plumbing& gas) the
homeowner will be respm e sure that the trades hired secure their proper
permits in conjunction ng p rmit issued, and',that they get their required
inspections. Failure of al tra s to secure the permits and inspections as
req uired can DELAY tntil such that
as the proper permits and inspections are
made
I, understand the above.
(Home owner/res'dent's signature requestin exemption)
I will call to schedul all required building inspectio necessary for the building permit
issued to me.
Date
Address of w rk
location
ti
AL
DEPARTMENT OP 8UILDP\IG INSPECTION'S
j 212 Alain Street Municipal Banding
jNorthampton, Mass. 01060
tip`ORt1 wS COwfPENSATTON MSUR NCF Al,MI AVIA
(I I CCII.S^�f Ixr'n1J iitx)
\VlLh a prim ipal plate of business/residence at-.
(sum tici ty la21zfri p)
do hereby certify, under tic pi'-.ins and penalties of per3ur -, -hat
( ) I am an employer providing the followine workces cotnocnsz for 111),
emplovccs %vorUng on Oils job:
;I
(Insuran=Cone) (Pont:Nu-mt�cr) (r:pirtior, l�aL}
I am a sole proprietor, general coot-actor or homeowner (C c:e one) aDd Dave hired
the conuactors listed below wbo 1-Lave the following worker's comper!shon pokiest
(l amc of Con.t^Cior) (Incur-ltt(:: Compai)-fiP0UCi ?�rum��:l -X)1FJ
j
(Name of Contractor) (Insurance ComoaayfPoUc Number) (—Expimtioa Dale)
(Name of Conn-znd;) (Insurance Company/PoUq- Numb`r) (Expimnos Date)
(Name of Conaaetor) (i.nsurano—z ComcanylPoliey Humber) (_xph6oa Datc) .
(.M-:b ad1i-�Ocz1 6ccf.if acccxa--y to inGJC=iafor=a.6.c perta.iaio.s to.11
I am a sole proprietor and bane, no one wor'dng for me.
( ) I am.a home owner performing all the work myself.
NOTE:pl=..be aoryrC tfi•• 60 vcra�-bo crnplcy per,0=to da r- _ -r oo a rrna••-oric on.d.•=rt;^y of
oflt tnorc th-a t`.s-o-_tetra in tc�id�the bocnoowp r r=dea or oa the a z�p�rte�r1 tcc o c o( riQocw b tosd od to he
ciVICY-- Lbe.=kcr'z o=p—�roo At-,(GLI 52=1(5)), pplintioa by>homco-=fcr a Gc .cc parch cr_y c`rda--
Icvj r+--,,of e.n esP loyar reader ttte Woricoe,Coazpamatioa Ad
I uadcnsaad t-x ooYy of thf.cmzt =m,.y bo for---d-d to tbo of low+ono ror the
eover+-o^c N"az siico AM 01-a L•.LM to somirc'toversse undcr=c ion 23A of MOL 152 can led to the ia2;K=60a of ciminsl peoattica
ooasitmg of a fix of up to S 1}00.00 andror iuP-tsocman of up to c=yt_ a od ovit pca>tia to x form o(a Swp Work Order and a
rtna of S 100.00 t day tpjD I Mn_
J For dcp.rczz�=-�u,c ody
(J,t!-/ (./('i �'f3Pe-- Lot tS
S i g><tun of Li�CCn5ccfPcnT6 cc L)Bte j
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: /� Not Applicable ❑
Name of License Holder: /o� �1'�' �� '� 053/ 0-7
License Number
(3 err LE1 S�Id1!)`�
Address Expiration Date
�L) 5112 '1
Signature Telephone
9 12e4sferemd m p am go— Not Applicable -❑
`ro r�A Ur `7CG,
Company Name Registration Number
1 d �e.fr 4- t d9 I be
Addre A / Expiration Date
A Cl l y Telephone
SECTION 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...... ❑
�W + Sa
r
The current exemption for"homeowners"was extended to include Owner-occu i wellin s of one(1) or two(2)families
and to allow such homeowner to engage an individual for hire wZched ss a license,provided that the owner acts
as supervisor.C 780 Sixth Edition Section 108.3.5.1.
Definition of H meo er:Person(s)who own a parcel of land esides or intends to reside,on which there
is,or is intended to be,a e or two family dwelling,attached or es accessory to such use and/or farm
structures.A person who constructs more than one home in shall not be considered a homeowner.
Such"ho meowner"shall sub 't to the Building Official,on orm acceptable to the Building Official,that he/she shall be
responsible for all such work&rformed under the bul],&ng Permit.
As acting Construction Su erviso our,presence on?(c job site will be required from.time to time,during and upon
completion of the work for which this rmit is issu
Also be advised that with reference to Ch ter 15 (Workers' Compensation) and Chapter 153(Liability of Employers to
Employees for injuries not resulting in Death the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you under this erm
The undersigned"homeowner"certifies d assumes r onsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and L al Zoning Laws an of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [tom] Decks [CJ Siding[O] Other[0]
Brief Description of Proposed
Work: '
N
Alteration of existing bedroom Yes No Adding new bedroom Yes
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
� � �+, �,-u^--,m�� `-s»:°r+•r s' ww°�r_:4""ry" - st�;�a" ,'"s:^"'�. °<<;-�"�. .�, .Y�"°`?� it, J_*."'�+'''
6— f 1e11VTo�sear>dodrtiortoexlstincr � sms compete�ii Oitowlnq:
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. Masscheck 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
SECTION 7a-OWNER AUTHORIZATION,-TO BE COMPLETED°WHEN
OWNERS AGENT OR CONTRACTOR A,,,P, t#k.600ING PERMIT
as Owner of the subject
property
hereby authorize T-0 M V t rl to
to act on my If, in all m ers re ti a to work authorized by this building permit application.
:kl
Signatur4A Owner V Date/
o a ,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.
0 ryl
Print Name
Z
Date
Signature of Owner/Agent
w .
' +
,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Vahunce/Findi ever been issuedfor/nn the site?
��
�� �� ��
N0 �� DON7KNOVV YES �~�
2F YES, date issuod:
IF YES: Was the permit recorded ut the Registry ofDeeds? '
�� VV
NO �� DONTKNO YES
IF YES: enter Book Page! and/or Document#|
'
B. Does the site contain o brook, body of water orwetlands? NO 0 DDN70UOV YES
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtoined /�� Obtained /-� �otm Issued:
�~� v�� ' .
C. Du any signs exist on the proport ��y? YES \_� NO
IF YES, describe size, type and location: |
D. Are there any proposed changes to or additions of signs intended for the property Y YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre orioit part cfo common plan
that will disturb over 1 oono? YES ��� 3 NO K��)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i
r City of NorthamptonasfPe"
r� nn wilding Department ' v '
^� U .: �.
? 212 Main Street
Room 100
AUG 2 1 2006 ;_,587-1240 hampton, MA 01060
phone Fax 413-587-1272 ,
L. �.�.� u
p
- APPLtC�dtl'S2IQ'P�CONST UCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE'INFORMATION
1.1 Property Address:
This sectIoreto be"'completed byoff,
S rMa got UgYt!
N
Zone Overlay f3istcict
��EUn�St°Dastrfct�r, +..: •_� . . CB Disfrict � -
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: ,
Lave, Lgf-S O.1 1'- Gfr'i r'P,Ly
Name Prin Current ling Address:
�9(-/ �7tyyS
Telephone
Sign re
2.2 Authorized Agent:
o.y Get„ (�� >� u �«l LnT�
Name(Print) Current Mailing Address:
g1_19 - s���,��
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS-
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building -(a)BuildingrPermit 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) '� v o1, 0(� Check Number S —
This Section For Official Use Only
Building Permit Number. Date,.
.Issued:
Signature:
Building Commissioner/inspector of Buildings Date
BP-2007-0198
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2007-0198
Project# JS-2007-000302
Est.Cost: $7442.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Quinlan Builders 101707
Lot Size(sq.ft.): 7666.56 Owner: LARSON LAURA M
Zoning:URA Applicant: Quinlan Builders
AT. 12 GRANDVIEW ST
Applicant Address: Phone: Insurance:
5 Hillside Dr (413) 549-5474 O
HADLEYMA01035 ISSUED ON:812212006 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 Occupancy Signature:
FeeType• Date Paid: Amount:
Building 8/22/2006 0:00:00 $25.004365
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo