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OSITE PLAN `—""XW W
Grz#y of Wart4alupta t z
�A65At}�liSttt6 -
DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060 ,
y
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 ,isor. 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
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 ��-'l„i 5 4 3
Address of work
location 5L"V c i�
��� 0 1 o k) � ',
' ��yt/•Nl�TU ��
,• � fib 'f' _
of N,art11aillp till
6 �ISSAt�tic r117
• I
z m DEPARTMENT Ot' LUILDING INSPECTIONS
212 Main Street ' Municipal Buildin,
Northampton, mass. 01060 r'
WORKER'S COMT ENI SATZON INSURANCE A.FFU)AN71.T
-
N"Ith a principal place of busiress/r :idenc
('ph o n c'=)
—
do llcrcby Ccr-uf • L'D^ 1 dic p li7S :11ik7 pen l icy 0l pc;r�llf}', lhi!l:
I am an employer providing the follov.,inC ' Orr:CI S compensation COVC'2 C Ur InY
elnployyces working on t?lis job:
(1=,L=a Coczpam•) (`rxTir,.Qon Date)
I am a sole pron;iet_or, generL C-Dncmlcror f-,. hon_eowop- (c—, le one) and rave hired
the contractors listed belotil the
(Ilamc of Contractor) Date)
(Name of Connmor) c7.Ilsur,nc Co_m_:I`•1Pchc-, i\umb,- ) (I ?:p rating Date)
(-Name of Contractor) J (IIhI ?11C� COi',:?n.i/'iOI;C: 1VUJI]lY'_r1 '.\'.I;:i:'c)-n- Date)
(Name of Contractor) —- (Ins1 Iallc Come_]y Polier ivtumr) - (I: :pi-:iio Date)
i
t 1 <llTl 21 :;olc prapnu"")i i'-i:1 havc no oIl^, f01- ?11c.
I am a honic o�v!)c- liCi-iC i Illin-, -ll
NO'n-.:plcnsc be mv: c tf:a:.ti ilc tx-r�o ir,s.r..�c�! ;r:. a:._� nc�ci,, r :m c :-;'air cilia;c.
not aK<c t1La uirco uni+,s in to rt Ix}: z� .tz r rc_: o cx a. ` _r,3 zo rtc:�r1 LhC o z c n.-{Cc wally c•_r:l;_:: :o ti
calployc3 urr,�cs t}x twti; s cc -�:_i^n,c (GL!52-c!(Sj;,-+:,•i:_:is;by z hntaco«w`cr z liccx CC P:r:t:i:: r c r
legal ctuuc of an loyot uod T ILIC Wn c1i nct;vr rlion?.cam
i undcr:tand that a copy of t}i a ctatc w.rv.y bo fo,w,vd J to tl»IY_t vt�un of I d ii ri l AtLiG'»iY C:too of i:�,tt e fot 1tx
-verase vaiTiclioo and that Lllurc 10 t-ti..tre uz-3-.r s4,:iM 25A of?.tGI,152 can lad to the imPOsitiao of e=�ir_I pctal;:-
coosuting of it f:rr-of up to S I SQU.CVJ n:t"'ct i^:�ri xZw.1 of::[r�to_c-.}- r/-.j civil;xru.ltin in d c fc,nn cf a
fIW oCS100.00 a dsy t�'.ina rnj . a•'�+"7 L{.•c J!''Ytt°K�. ---------`- u.c
&� �-
yv�„��,�p,,,�/"//�2!
Y
S€CIANBR CONSTRl7CTION..;SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
.9Reg s e Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION iO WORKERS'COMPENSA',ION 1NSURANCE: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...... ❑
RR
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-vear period shall not be considered a homeowner.
Such"homeowner" shall submit to the Building Official,on a form acecptable 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, St at ocal Zoning Laws and State of Massachusetts General Laws Annotated.
omeowner Signature
5,�.,,."� V J r x�n UhG� J� a^Q- L,�'°hr's('�7 nl� �� �►� pie— l�`� SC��-cy-C "'
�zv ;
SECTOTfs'�E R FTJON®FPROPOSEDYYORK check alll a lecable �x um
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: ��-r�� '7` ��5'.� � ��1/Z
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
rof a"ddfflo`nfto a ci'§,fi 4h uo sing co pJe a e�f�`Il� nw
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 Nc
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
{
SECfi�OkTt1TY[ ERAUTi�ORfZAT10N TO;BECOMPLETED WHEN
OWNEFSGE T. R�GONTRACTOR APPLIESFOR BU1L'DING PERMIT.
I' aAAQ as Owner of the subject property
hereby authorize J�: L /66 J to ac; or
my beDzILin all matters re Live to w authorized by this building permit application.
� Q
Signature of Owner Date
I' �, C'— 1), A as Owner/.Authorized Agent
hereby declare that the statements and inh0malion on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signe r the pains and penalties of perjury.
Print —
ignat 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
Building Department
Lot Size3� G, s
Frontage r
Setbacks Front
Side L: R: L:-"W R:�w
Rear /Y 2
/ 0
Building Height
Bldg. Square Footage % �
IG
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: �.M
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO ✓ 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:
C. Do any signs exist on the property? YES f/ NO
IF YES, describe size, type and location: Q K 5%. 4—
IV
D. Are ere any proposed changes to or additions of signs intended for the property ?YES _
No
IF--YES, describe size, type and location:
City of Northampton
,Puilding Department
212 Main Street
Room 100
Northampton, MA 01060
t ty r 3 0 - 2 p�� '
rT
ICATION CONST UCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
,.
SECTION 1- SITE INFORMATI,O.N
This sects°oto'ti competed off�ceA
1.1 Property Address: �� �':. � ��� L :5.�- q�w ,.;
a
Elm St Di'trict' r „GCB 13�s ct -
SECTION.2 PROPERTY-OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
11 .7ez.— 11,0e Z4 17 114 7 i 469 X aG f T' l
Name(Pri Current Mailing Address
�
l.. r Telephone
Signature
2.2 Authorized Agent:
Name );Tint) Current Mailing Address:
Signature Telephone
SECTfON..3 - ESTIMATED`CONSTRUCT!ION COSTS
Item Estimated Cost (Dollars) to be Official use•Drily
completed by permit applicant
1. Building 7r,2 pf (a) Building Permit Fee
2. Ele rical (b) 'stimated Total Cost of
w115t Construction.#rom 6
3. Plumbing N Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) X20'0, Check Number
This Section For Official Use Only
Building"Permit Number: y'` 3 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings...,, Date'
% I
File#BP-2004-0534
APPLICANT/CONTACT PERSON Pioneer Valley Habitat for Humanity
ADDRESS/PHONE 434 N.Pleasant St (413)256-8250
PROPERTY LOCATION 840 WESTHAMPTON RD
MAP 42 PARCEL 165 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid �rj,3 AFJS-
T_yt tion: ERECT 8 X 12 SHED
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 L OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO 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 Str t Commission
L
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.
840,WjF tHAMPtON RD BP-2004-0534
GlS#: < COMMONWEALTH OF MASSACHUSETTS
1p:Block:42- 165 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0534
Project# JS-2004-0755
Est. Cost: $300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): Owner: Pioneer Valley Habitat for Humanity
Zoning: SR Applicant: Pioneer Valley Habitat for Humanity
AT. 840 WESTHAMPTON RD
Applicant Address: Phone: Insurance:
434 N.Pleasant St (413) 256-8250
AMHERSTMA01002 ISSUED ON:11114103 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 8 X 12 SHED
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• Receipt No: Date Paid: Check No: Amount:
Building 11/14/03 0:00:00 2953 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo