17A-260 a
Clitp of Xart4aiiiptan
M 7
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street * Municipal Building y j
Northvnptcm, MA 01060
r�
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 1083.4 to
act as !Js/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
divelling, 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 ?/�� U
Address of work
location e9 C)a/( 5 r __
g � 6 Yi�ISaFrflctcrfls j;� _!
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212 Maki Skeet blunidpd B&Minj,
Northnnq)tan, Mask 0100
VVoIZTCIIZ'S COMPENSAT[ON INSURANCE AFFIDAVIT
%vith a pI ificipal place
do hereby cc 60, is V K ,1"'i �)I
all -,Il cnlpioyci
cnlploycc-5 wolkiny', oil
—— ---------
Coaipazyll
I SHI a SCIC prouAcyn. (ClICIC oll�) anc
the contractors Wel bd& V, - To
almne of(Inmacua av mnn.v
(Nam.. of ArVICUM Onwincc
(Name of Convarna t
(Nwne of Connaa, Da
till it Sole
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'ICA 12"-C thni thrc 1%11'_1 l•l\0:•cn 1,
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API"-wa of an—phyn wAnW.A"Wn C"q—vm�Am
I un<ic--rtnd thit a copy of thi,rt,tr::s: t,!-, ,-,ioi to I!,,tvtxii C,ucL of
—CZI&C vc-ifiicztioo rind that flilul-c'M-':1:z!:-, p to Un owt no 25A dM CL 152 can lad to tlx ill'!- sIficll
0:)-u,Ii3tLng of a f',jy-of ug, to S I ODD 00 mV"kym no A&UP to,w)-�r...1 Civil lxrulli<s in:1,
fir--OCSM.Ofl I d-ty
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SECTION 8'-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder :___ _ ___ --
License Number
Address Expiration Date
Signature Telephone
war.... , -� P�� � gall Not Applicable
�R'etristered
MOB 26676: ent�Contractor „ „as e r ti.x
Company Name Registration Number
Address Expiration Date
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...... ❑
The current exemption for"homeowners" was extended to include Owner-occupied Dwellings of one(I) 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 buildinE 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 f'�-which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers` Compensation) and Chapter 153 !,iabiiii� of Employers to
Employees for injuries not restihin<u, in Beath) ofthe Massachusetts General Laws Annotated, you ma�_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, Cite of'
Northampton Ordinances, State ai i Local /_onino Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature �y� — _____ _
I
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement ndows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] DeaKs [ ] Siding I—'Other [ ]
Brief Description of Proposed Work: I Pn-issv_� r � nom__ O(Ll < ____
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet ❑
6a. IfiNew house°and or addition to° existing hdusili complet"hO 61 o'winir;
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
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 APPLIES FOR BUILDING PERMIT
as Owner of the subject propert
hereby authorize _ ___ _to "D r.
my behalf, in all matters relative to work authorized by th )uildirF, rerr-nit application.
Signature of Owner - - Date
I,
— — - — ---_.--------------- --
as Owners Wt�-ior,zed Adent
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.
----------__-.--- -
Print me
Signature of Owner/ ent Da e
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 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 #
E3. Does the site contain a brook, body of water or wetlands? NO ✓ i)ON'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 atus of P r a
y.
Building Department CurbC tJD. e `
12 Main Street �fe lie- is ala
'{ MAR 17 20U F o
� 5$
Room 100 Water& ells va 3D I
Northarrl.pton t MA 01060 T.wa Sets�o Str e Pans � �
phtt 41 '6 X240 Fax 413-587 1272 Plot%31te�Plans A �'#
-
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to,be completed,by office
29 0(2 ST Map Lot Unit
Zone Overlay-;District
,L11 Elm St. District CB District -
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name 'rint) -;..rrent Mailing Address s:��
signature
2.2 Authorized A ent:
Nance(PI Int) ,rrcnt Mailing Address:
�i�nat�re -- ------ _ _
er.n�ne
SECTION 3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
_-- com feted bvpetrnit a plicant
1. Building (a) Building Permit Fee
tiMated Total Cost of
------ -- -------- —� - -- - - L enstruction from (6)
f-----
Plumbing Buildin g Permit Fee
, ti�echanica! (HVAC;
firF Protection
6_
lot- ! -- (1 + 2 + 3 + 4 + 5j�- 1 Check Number
This Section For Official Use Only
Building Permit Number: Date Issued: _--. -
I
Signature:
---- ---
g - — --------- --- ---- - - - -- - -- ------ -
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Building Commissioner/Inspector of B11iiidings Date
89 OAK ST BP-2003-0754
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man:Block: 17A-260 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Catesorv: BUILDING PERMIT
Permit# BP-2003-0754
Project# JS-2003-1237
Est.Cost: $13500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 10890.00 Owner: GRAHAM ANNE&SCOTT
Zoning:URB Applicant: GRAHAM ANNE & SCOTT
AT: 89 OAK Si
Applicant Address: Phone: Insurance:
89 OAK ST (413) 586-3549 ()
FLORENCEMA01062 ISSUED ON:3117103 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE ROOF, SIDING &WINDOWS
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: 0 jk
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIO N F
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu an Si nature:
FeeType• Receipt No: Date Paid: Check No:_ Amount:
Building 3/17/03 0:00:00 2630 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo