17C-287 (3) JELLY BELLY'S POOLS & SPAS AA5
58 SOUTHWICK ROAD PO BOX 936•(413) 568-1700 FAX (413)572-1218 • WESTFIELD, MA 01086-0936
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" DEPARTMENT OF BUILDING INSPECTIONS
212 Maio Sn-eet & Municipal Building
INSPECTOR °
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 iris/her construction sup ,or. T he state defines "Homeowner" as, Person(s)
who owns a parcel on which he/she resides or intends to be, a one or hvo family
dfvelling, 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
*=me,o2wner understand the above.
/resident's signa ure requesting exemption)
I call o schedule all required building inspections necessary for the building permit
issued to me. �f
Date < 0�
Address of work
location
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r � DEPARTMIENI' OF BUILDING INSITCl'IONS -
212 Main Strect , Municipal 1133ifiltliu1,
Northampton, Mass. 01x0
«'ORIChR'S COMPENSATION INSURANCY, AFFIDAVIT
v"ith a principal oiac(� of business/residellec at 0�0�S
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SECTIOtJ;8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
r
Address Expiration Date
Signature Telephone
9 Re s� . .ff Mr n C ,_ Not Applicable licable ❑
lab 9a �
Company Name Registratio Nu er
p 8�0o D b
Address Expiration Date
Nei ( ' / � Telephone 5
SECTION 107: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(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,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 _
SECTION 5 'DESCRIPTIONiOF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [\A
'4 17
Brief Description of Proposed Work: f ���G S M111f
Alteration of existing bedroom Yes J_No Adding new bedroom Yes ( No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 11 - Sheet`�M
sa If New house and o�adtlition=to:ezi'stfnga ousing complete th6,J6 lowin :
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. ODD Dimensions 33
r
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 4 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
OWNk' AGENT OR°CONTRACTOR APPLIES,FOR BUILDING';.PERMIT
I, .�civ11e s G 'For. 'YSTG. � � �Q-V1rA � �"G(0� as Owner of the subject property
hereby authorize to act on
my behalf, in all m>attprs relative to work authorized his build in ermit application.
Sig re of Owner Date
�� I Q dn1�5 ✓'°J l�f �� rQ`- f )
-U GwJ 1�+ 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 erjury.
' �� ��QS 'Al�✓ ---
Print Name f� /
S ature 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 Size
Frontage
Setbacks Front ?5•je
Side L: R: L: /D R:
Rear
Building Height
Bldg. Square Footage 'Xq % 4Atg
Open Space Footage a�70%(Lot area minus bldg&paved Po
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/FindinJJJg��� ever been issued for/on the site?
NO DON'T KNOW (v 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 #
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 NO
IF YES, describe size, type and location: l
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No —P
IF-YES, describe size, type and location:
{
.City,of Northampton
r �r + ilding Department Gur
212 Main Street
Room 100a r v
Northampton, MA 01060
tyq,�Y 1 1 �uGS p
phone 413.587.1240 Fax 413-587-1272 I?lo /Slte R
,C
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This sectia to' be&completed by office
1.1 Property Address: a � N
J Map
Zone Overlay District
Elm St. District CB Distrct
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: J �p
7�meo f:�OrJ'?P R'/l
Nam"(Z44'vt' Current Mailing Address:
Telephone 5
Signature
2.2 Authorized Agent:
Te((
Name(P i /�} s� s Current Mailing Address:
Signat re Telephone
SECTION,3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building r4 (a) Building Permit Fee
2. Elecirical ®C a UQ f U (b) Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(I + 2 + 3 + 4 + 5) $ Q'°U Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: -- —
Building Commissioner/Inspector of Buildings Date
File#BP-2005-1117
APPLICANT/CONTACT PERSON JELLY BELLY'S POOLS&SPAS,INC
ADDRESS/PHONE P O BOX 936 WESTFIELD (413)568-1700
PROPERTY LOCATION 46 LILLY ST
MAP 17C PARCEL 287 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERM_IT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid ZM71 90U
Typeof Construction: CONSTRUCT 12 X 35 INGROUND POOL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 126929
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9&MATION 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 'ssion 9
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.
46 LILLY ST BP-2005-1117
G1S#: COMMONWEALTH OF MASSACHUSETTS
MM:Block: 17C-287 CITY OF NORTHAMPTON
Lot: -001
Pen-nit: BuiidinQ
Category: BUILDING PERMIT
Pernut# BP-2005-1117
Project# JS-2005-1510
Est.Cost: $15200.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JELLY BELLY'S POOLS & SPAS, INC 126929
Lot Size(ss . ft.): 9844.56 Owner: FORRESTALL JAMES E&
Zoning: URB Applicant: JELLY BELLY'S POOLS &SPAS, INC
AT. 46 LILLY ST
Applicant Address: Phone: Insurance:
P O BOX 936 (413) 568-1700 Workers
Compensation
WESTFIELDMA01086-0936 ISSUED ON.5119105 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 12 X 35 INGROUND POOL
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 5/19/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo