17D-055 (6) 4'St1AMPT z
O O
J�85EAC1'1[EtttE -
DEPARTMENT OF BUILDI]\'G INSPECTIONS /-
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction sup,-,., .-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
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
M
F yE 6I[�] Of ��tTl fl�cilll�)fDll
-
a3 aerh nrcf I z' -
�,
DEPAR TMENT OP £tUILDr1\G INSPECTIONS
212 Main Street Municipal Building
Northampton, Mass. 010GO
tip`ORI�f:IZ'S C(� CI'ENSr1_nON MSUTAHCF AF=, AVIT
I
0' Caste PCT itfcc)
\kliLh a p(-incipaj place of busIDcsSJrcSidence at:
p.
1, (sn-�tici iy/stal.cln p)
do hereby cerg).-, under t}1e pains cad penalties of pcgur ,, --hal
( ) ng dic following worker's comocasado, cove gc for 111),I an an employer provid111),
emplovices woriang on this job:
oms- nn=Conr,�_cy) (polio:NU-mir_r) (r:-pirtion Dom)
CIaimai a sole proprietor eoeral contractor or hotneoivzer (ccie ot?e) ahirea
the Blow crbo have the following workers coLa°nt26on policies:
i
(i;,qmc Of Cont^cio-) (In2ra1lc: CO1r101+1)YPGhCi ?"`UIRL{;) Date)
(Name of Coolraor) CompanwPolicr Numccr) (ixpim6on Date)
i
(Name of Conn-aclo,) (Las rancc Company/PoUq• Nambu) (1=xpir6eo Dam)
(Name of COUMCIOr) (Insumcc Company/Pobcy Number) (Expir-Jtioa Date).
(.IISCh=ddi-:Oca1 r!--if 000=-'1'to 61C U.:6 u.for,E.QCTtaialas b..tl mQTLA:]) .
(/I a sole ro rietor and have no one worm g for me.
P P
( ) I am.a home o,,vner performing all the%vork tnyseif.
NOTE:plesc be eww,tbz:wjijc at, znplay p--L<=tn d�r- - o_.cjoc cr rc air work m.d..c11_ of
oot tnocc the-c Lhz --=r s is%ia a the bomn o, r r=do or oa the g-oua zppurtcn_r1 tb_- r.-r D x C— --Uy o<=.d.ud to k
caq�loyc-s t,..t_.the.+-xS;dz 000v=:-tioo A=(GL152=1(5)),a.ppU=L6oc by a bomooavc for c lice_or l amh=y n4dc�LLc
lepi cL%-Lu or en esaloyx uoder do Workora Go¢tpomatio Act_
- [—d---d tha>Dopy or thu mu m.y ba f.--rde to Lb.pegartisvoo¢er A dau.y offiw or 41—ror tn.
oovcrxFc vrlilie3lioa and th1 Liltze to ccauc' -cruse imdcr satioc 25A of MOL 151 c a a ted to the i�aoa of eiminA p c a z.1 6,-
o o m i s m g or a f i n e orup to S 1 500.00.nsclr i=gr600mert orup Lo ooc y e a r tad Civil pm.ltia is c c roan of.Slop work Order end e
rim of SIO0.00 a d_y aptia-a me
` For 6cp.rta'�l u,c :,I -
j,,(npV permit Numb=tore o Li crmiucc e -- Lot
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable O
Name of License Holder: ,ehK�/ - �'� 013 G(el'
License Number
130A 490, 1-,e-t4�f , 010 s J 7. zV{ Zoo7
Address Expiration Date
tt,PZ
4- ture Telephone
I1..Re int tc f o'� Not Applicable_❑At m rove-went Ceed a
44, t34477
Companv Name Registration Number
�I A,4C41-V, o, fr33o y 3 - / Zac�
`� j� Expiration Date,
Address
Q� �)"' . C.3 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...... 0
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-DESCRIPTION OF PROPOSED'WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[p]
Brief Description of Proposed /f � 'r U44- n
� � �
Work: ��fA !W 0� G f /tQ
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes t�No
Attached Narrative Renovating unfinished basement Yes /No
Plans Attached Roll -Sheet
Or Mr
sa�lfVewtoase- p k a a ean �r � to elsla4ou mx vup:
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 7a-OWNERAUTHORIZATION-TO BE COMPLETED WHEN 11
OWNERS>QGENTOR CONTRACTOR•APPLIESFOR=BUILDING.PEi2MIT
✓ c /l Atft; e,✓ as Owner of the subject
property <,,, �& (A) - � L4 C,4 5 C—�
hereby authorize
to act on my behalf,in all atters relative to work authorized by this building permit application.
--W,44 /V R D
Signature of GKner Date
I,
Q 0 ` L wed! A `o? •Z— L as 4 w mWAuthorized
Agent hereby declare that the statements and information on the foregoing applic ion are true and accurate,to the best of my knowledge
and belief.
Signed un er the pains a d penalties/of perjury.
Print Name
Signatur /Agent Date
,
^ -
^~ ^
�
'
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage % r-7.
Open Space Footage
#of Parking Spaces
(volume&Location)
A. Has a Special ever been issued for/on the site?
NO 0 DON7 KNOW YES 0
/F YES, date ioued: |
IF YES: Was the permit recorded at the Registry of Deeds?
'
NO 0 DON7KNOW YES
IF YES: enter Book Page': and/or Dooument#'
'
B. Does the site contain u brook, body of water orwetlands? NO �_� DON7KNOVV YES v~�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Nmedstobeobtainod �-
\ Obta�oed �~� Dote Issued
«�� k_� ' '
C. Du any signs exist on the propert ��y? YES �~� NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? yES0 NO
_
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,o,filling)over 1 acre orinitpart ofo common plan
that will disturb over 1acre? YEG ���} NO ���M
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton x �
—S'pli ding Department
`212 Main Street
Room 100 °
NIhampton, MA01060 � � � r
2
OCT p e 4,IZZ-1240 Fax 413-587-1272
- u APIF�LIC `IORi STRU T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: Thissecttuntobecompietedbyaf£ce
�t✓/ f /,vQIKap l°.�t Uuut
F7/ ✓'G N t.� �"' Zone " ; QverlayA[strtct -
t:1WZt.
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
U � c - 6iS3
Telephone
Signature
2.2 AAuthorriiz(e�d�Acient:
CA •'� G �•0 , U�� 7 1 C t C rC�. D 4D.F 3
tame rint) Current Mailing Address:
J 1..— y/Td/! 12-'?Z.-
ture Telephone
SECTION1-ESTIMATED CONSTRUCTION COSTS=
Item Estimated Cost(Dolls )to be Official Use Only
completed by ermit a licant
1. Building r -(a)Building Permit Fee
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) Z po-�- Check Number
This Section For'Official Use Only
Building Permit Number. Dsued:
Signature:
Building Commissionedlnspectorof Buildings Date
116 STRAW AVE BP-2007-0420
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D-055 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Cate ory: BUILDING PERMIT
Permit# BP-2007-0420
Project# JS-2007-000627
Est. Cost: $4200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin KENNETH LYNDS 136677
Lot Size(sq.ft.): 8145.72 Owner: MEUNIER MARK
Zoning: URB Applicant: KENNETH LYNDS
AT. 116 STRAW AVE
Applicant Address: Phone: Insurance:
P O BOX 448 (413) 584-9282
LEEDSMA01053 ISSUED ON.1011312006 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 10/13/2006 0:00:00 $25.003373
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
116 STRAW AVE BP-2007-0420
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17D-055 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2007-0420
Proiect# JS-2007-000627
Est. Cost: $4200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KENNETH LYNDS 136677
Lot Size(sa. ft.): 8145.72 Owner: MEUNIER MARK
Zoning:URB Applicant: KENNETH LYNDS
At. 110 j 1 RAVJ AVE
Applicant Address: Phone: Insurance:
P O BOX 448 (413)584-9282
LEEDSMA01053 ISSUED ON:1011312006 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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: OK l a' pC 3
THIS PERMIT MAY BE REVOKED BY THE C OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc Si nature: 4-
FeeType: Date Paid: Amount:
Building 10/13/2006 0:00:00 $25.003373
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo