17C-285 O¢�t1AMp�O +
_Cify of� � �i'ilassat3tuscttts
DEPARTMENT OF BUILDNIG INSPECTIONS
212 Main Street • Municipal Building
INSPECTOR Northunpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as has/her construction supe."::aSor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two-anu y
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 buil ing department for the City of Northampton wants-any persons)who-seek-to -
use the home owner exemption, to act as their owri 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 ff undation/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 gbtain 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
L �fa 0 D J, l'1'1 C/A'S o/J understand the above.
` ome owner/resident's Siabn...a.ture requesting a exemption)
I will call to schedule all required building inspections necessary for the building permit
issued-to me
Daze I/o?
T
Address of work
location ,S o2- Lc 1 ( !I
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� .F E U-If� L7� ��Q�f1�3111�7�'011
P y f t3awchnfctta'
d DEPARTMERIT OF BUILDING INSPECTIONS
212 Alain Strcct Municipal Building
Northampton, ATass. 01060
I
Vr'-OR1tLIZ'S CON-fPENSATIO.N L'ISURANCE AFFID,, Aj-j-
���itlz a principal place of business/residencc zt: - -
_ (f honer)
(sit/ci rJ/Bair/��)
do hereby certify, under the pains and penalties of peg ry, hzr
j ( ) I am an employer providing die follo,,vine!workcr's coinocnsado, coverage for ink
i� emplovees Nvorlong on uus job:
I
i (Lsur�c Conr`cl) (Poiic:?:u ibc -- (r:•pirction Dztc}
( ) I am a sole proprietor, geaeral contractor or homeowner (ci:cie ohe) and have hired
I the coon actors ltsi below wbo have the follollvmg workers compen_sa6on pobcies.,
i
t r-) •on D.-Itc)
o.Co�tr.IC,o-1 (lRStrant;; COI12D1f1y!l�GUC'i ?�`utI1=_. �tiJli1::_e.
1 _
(N mlc of Conc-zaor) (Ins-arzncc Comoazvipoljc�, Nuncrr) (E%tii—,6on Date)
(Name o CConrraclor)
� (I.nsulancc Compan3'lPoliq• N:tsbcj) CFA.xDuraon I?atc)
I
(N2me of Coatraaor) (insuraacc CompazyfPoticy Numbc-r) tri�irrion Dale).
I
(aaa.d,�+'+:�001 c'x�d..irnceev_-ti-w a�cv�ia(ocm 'ioa petniai.a6 w.11 cec-ra:-a) .
jO I am a sole proprietor ana bane no ooe worlong for me.
TI am,a home oivner perforT=g all the work myself.
,I
INOTE:ptcsc be cwarc Lz Jc hcmcvxra who csploy pct ona to cb -, c:c,�c rc u.rori w d.•cJl_Z of
ant Inoce L�'i t`u--o:testa is ta'stsz Ibe botnoowoc rtaid�a oo the p-oeea z�p�:tte�•-tyceo e.-c ox :-UY -d- d to L-
i cxxpioycs u�.c Ibc kci:��---,-oa Aa{GL152�t(5)1�ptin:iw try.bomcoax fa c lip.«pc:ait�y c��mcr tl:c
lei.!et.s-'ue or en c:,PIoyee-ad,d.woe,c ,comPam,atioc Ace- '
i
'I I yadert4nd tba a oo"of 016-=-L-c—ov.y be to cbu p Lmmi or IodacYrici ncedaa7'OT—or I=--for tb.
cove o^c rc-iCc:ticc and nu r_irtac to soauc roovctasc t=d.—scmlca 23 A of MoL 152 da Icd to the i-prni6on of cr i.,t Pm"-16C'
eo=i=!=z of a fiat or up to s Soo.00 and!«impriaooma or up to ooc yc_r tod cNil pca�j• is dSc focm ora Slop work Ordc and a
rum o(S 100.00 a d_y r pF Siaza co, -
For dq.+ta.�=1 u.c onty
permlt Numb-
Sti"r�'Z turf o iruG-1Pcrmittc:. e
SECTION 8-CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration Num er -----
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT"(M.O.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...... ❑
Omemw
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 ion 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 acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building germit.
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 persons)
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
r
s
SECTION 5-DESCRIPTION- WORK(check all applicable)
New House F--J Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors M
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[0] Other[p]
Brief Description of Proposed
Work: .5:10�Rtp hnf t� Roc A/2 cd Rc o
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roil -Sheet
f"l�eivawse �ict�iia�ci`cai xls" crausirlc> iFitete,ihf [f+auing:
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 7aOWNER AUTHORIZATION-;TO.BECOMPLETED WHEN
OWNERS-AGENT OR CONtRACl'OR APPLIES FOR!BCIILDINCr PERMIT
I, as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, 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.
Print Name
Signature of Owner/ nt Date
Section 4. ZONING All Informatibn Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing P oposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front (— 11
Side L: ' Li R:I
Rear
Building Height T?
Bldg. Square Footage
t
Open Space Footage _ %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill: r —
(volume,&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
N0 0 DON'T KNOW f-lt*N YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW Q YES 0
IF YES: enter Book Pager and/or Document
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES 0
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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO t
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
,~C.ityi,of Nortoampton �gso e
1[ °tlilding Department y �� �►
212 Main Street `er
Room 100eaala�t .
SFP 2 6 2005 N66 mpton; MA 01060
4�
phone 413-5811-1240 Fax 413-587-1272ota °
15ttte5aecfiy _„ 4 �
-APPLICATION i @C T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIONA -SITE INFORMATION
, This secttorr to be com�letedl by office
1.1 Property Address:
L i 1 l-v
r�o R eNCe In A
Zone !O�rerla�Drstrrcf
a;
Elfin St Distract CD�stnct
SECTION:2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
moo ” rift elC'�or�0 L c.�1 Y s 000 e+ju e ,FV�,q, rsr o a
Name(Print) / Current Mailing Add ss:
!I• Telepho e t
Signature t " -3 14
2.2 Authorized Agent:
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 �a (a)Building.PermiYFee
'7CJ b;
2. Electrical (b)Estimated:Total Cost of
Construction from 6
3. Plumbing Building:Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number: ''-'Issued:
Signature:
r
Building Commissioner/Inspector of Buildings- Date
32 LILLY ST BP-2006-0327
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-285 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0327
Project# JS-2006-0482
Est. Cost: $700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 9234.72 Owner: HICKSON DAVID J&DARLENE J
zoning.URB Applicant: HICKSON DAVID J & DARLENE J
AT. 32 LILLY ST
Applicant Address: Phone: Insurance:
32 LILLY ST (413) 586-3435 ()
FLORENCEMA01062 ISSUED ON.912612005 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE BACK ROOF & SIDE PORCH
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 9/26/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo