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G1 y of Nort4ainpton
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,y DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supc:-,•isor. The stale 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
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z L)LP,u2TMENl- OF LUIL)WG INSPECTIONS
212 Main Street ' Municipal Building 'o
Northampton, Mass. 01060
WOMCCR'S COMTENSATION I SURANCE /I FIDAVI.T
with a principc-j place, of busir�ess/r�_:�idcnce t:
phone - `W'_`. '�,
CIO hcl- )y CCIi1Ij'; Ul`A::r the 1)%illS laid pcn 1ticS Of 7�;5Jt1S�t, '.hF+.i:
1 am do employee- providing the colnypc!)Satiol] COVCI<: C Or II1}'
employees •working on tills job:
(InszlanG: Company) Cc;Number) ----- (r��ir clan D2ic)
j I a-r--i a sole proprietor, general c�:l=:or or hC21eOWDe7 (CLCIe one) and hired
the contractors listed beiov;w o ;: .. the oll - oriters co'pen��on o! cies:
CName of ConLmmor) (TnS' P.1C CoI ^-;iY;PG!.]Cf TvIllIIl I) (TX!`:rIliiO'Datc)-
(Name of Contr:ctor) -- �i1Sur P.Ce COT�c;i�'/PO'.1Ci L rilb^f} (t `; i10 Dale)
(Name of Conni clot) (IDS 2i1c Cou ;:'_ ;I:�oI;C: 7v'lulll} r) =.x;.]ra l'".a Dal,-,.)
- (Name of Contractor) — (Ins, sic Col m_,yfPoLiry Numb r) (E:;:ri-:tier: Date}
1 i1IT1 it ole 1)IO1)[1CtOi" il'i'1 llavc Il O :� 1 to 1
OI 'V :;.lilt ii ".
( am t! hO?lie oWIIC
NOTE:plc:sc be awarc t1:1.',vLilc c:
not utccc tt>:.n throo uniu in t i c r 'x 1:-z ;•,tz�r o; •::.�z ut cr_r1 L cc o c c n t�cxrall i a�:'t`:cc h
C=ployc3 u.�ttr-tvo:Ixrls cc z•_:eti o %c'((73!1,M,:-.-,:(St1•r.+:ii_:;ic::Ly a hotnco,--xs for e CCC`✓.,oc p-s::c
Itsal C-,=UA OF=e;,zployx under dan Workc1[
I unde.=�ind ihxt a copy of thLi etate:s•ruy bo fa—Ud j to tl�l-jt L- -a Aci'sd"t>'offs w of tar tfx
coverage vtzifie=tioc and Lhat fi-dw-r to f=—'c 25 A of?.(GL.152 can lc_d to the i tTpoz repo of c r l pe nL.a
comiuting of a fur_of up to S 1-�0(J.CNJ[:tom'f i :pre. zti; or;:p to cr,:}- r-.i civil,crultiu in do reran cf a S!c-,+';V` i* Ord _:"j t
f rn-of S I 011 a diy[^:in:1 rry- .
Fcx ci�;a:tna�til u.c cftly
" l�t7Illll NIIIIltY.jr
_ 5i:,natifrc c t.i�c^• . •.� 'c'.rrn;a:_.� i F
SECTION 8 CONSTRUCTION SERVICES''
8.1 Licensed Construction u ervisor: Not Applicable ❑
Name of License Holder ,({�C j 71 i
License N ber
v7
Addr s Exp tion Date
Signs re Telephone
UNI a r sfere ome//m r: uernen Cont`ra'cto s Not Applicable ❑
Company Name Registration. Number
Address Expiration Date
l Telephone
SECTIONIO WORKERS' COMPENSATION 1KSURANCE 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"homeowmer"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
1 WE
SECSIOt S=IDES 1P�T�tOT�'OF KROPOSEDWYORK check�all a ticable) '
New House ❑ Addition ❑ Replacement Windows Alteration(s),(7 Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ j Decks [ ] Siding[ J Other [ ]
Brief Description of Proposed Work: RWA /O'kL,-) r..R. * '4—
Alteration of existing bedroom e' Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 -Sheet
6a�tfiieouse"a" "d; ditiontoezistin , hoi sing;c�oi"p.let"ethefolaow�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 regulati.ons? Yes No .
i. Septic Tank City Sewer Private well City water Supply
SEC>klOf�7a OYYNER1jTHORIZATl01V TO BE COMPLETED VYHEN
OWttEFfS�GENVOR O'01N 9ACTOR`APPL1E5 FOR BU{LDING PERMIT
as Owner of the subject property
hereby authorize C ' to ac;. on
my behalf, in all matters rela ' e To work auth rized by this building permit application.
Z"LAt2sA_V_ 11123
Signature of Owner Date
/A as Owner,.Authorized Agent
hereby declare , at the stat ents and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed un er the/pains and penalties of perjury.
Print Na e
Signatu e o ner/Agent Date'
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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
i
Lot Size j
I
Frontage
Setbacks Front 1
Side L: R: L: R i
Rear
Building Height
i
Bldg.Square Footage %
i
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#
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:
w
.
City of Northampton
M
Building Department
6 ,•�, Z12 Main Street
Room 100
Northampton, MA 01060 „
pho�i '4.137t87-1240 Fax 413-587-1272
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APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This secfion toEbe completed uy ofEce
1.1 Properly Address: sm ' '
PAN '#Jn
Zoe Overlay Distract
dm St.Distract * > ° GB Drstnct z`-
SECTION.2-PROPERTY O'W'WNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
e'oze T C1.cy�l S1A
Name P" t) Current Mailing Address:
Telephone
Signature
2.2 Authorized Anent:
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 'ta)BuildingPermiffee
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) /?a"y''x Check-Number -O This Section For'Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2006-0661
APPLICANT/CONTACT PERSON Craig Marney
ADDRESS/PHONE P O Box 128 LEEDS (413)586-5512
PROPERTY LOCATION 3 MOUNTAIN ST
MAP 17A PARCEL 088 001 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
T_ypeof Construction: CONSTUCT 10 X 10 BATHROOM IN EXISTING 2ND FLR BEDROOM
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 057159
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 Co scion
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.
Y'-- As Iq kA Ct;
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BP-2006-0661
MOUNTAIN OUNTAIN ST
3 M#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Map:Block: 17A-088
Lot:-001
Permit Building
BUILDING PERMIT
Category:
Permit# BP-2006-0661
Project# JS-2006-0974
Est Cost: $19000.00
Fee $50.00 PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
Const.Class: 057159
Use Group: Craig Marney
Lot Size(sq. ft.): 14810.40 Owner: PEASE SARAH A&LINDA SHARKEY
Zoning:URA Applicant: Craig Marne
AT: N I N N -ST
Phone: Insurance:
Applicant Address: (413) 586-5512
P O Box 128
LEEDSMA01053 ISSUED ON.]211912005 0.00.00
TO PERFORM THE FOLLOWING WORK:CONSTUCT _10 X 10 BATHROOM IN EXISTING
2ND FLR BEDROOM
POST THIS CARD SO IT IS VISIBLE FROM THE STREET Building Inspector
Inspector of Plumbing Inspector of Wiring D.P.W.
Meter:
Service:
Underground: Footings:
Foundation:
Rough: j/. House#
Rough: / (, ��� f/(s �j(, Driveway Final:
Final: °7 'Ob Final:4, 3" O b Rough Frame 0K J—c7.0 �
`P,o#4'i J4
Fireplace/Chimney:
Gas:
Fire Department
Insulation:
Rough: Oil: /
ke: Final: Oil G ZI e°�/ 06 60c4i5
Final: Smo (((
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.,-,!
Certificate of Occu anc —
� Si nature: J
Feel e: Date Paid: Amount:
Building 12/19/2005 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo