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LOCUS REFSVEACE
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AXD: First American Title Ins. Co.FAU
John. T. Golling
Kathy A. Golling
LMATIONIbeeft"Pa" &-Pw Ye�i�o�umitboawc113 North Maple Street
bowdvXft* wd Amw *moo@ 1wNorthampton, Massachusetts
Pe"
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNM 108.3.4 to
act as his/her construction sup(: %eisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or twofamiTy -
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),
cnnntnhP hnlec thefnre nour). a rouLyh building inspection (before work is
uired) 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 1 f '
locdress ation on of wok I _I � / J %(I-
1
i �.
q
..
,Pf �\Taril}allipjott
gitsanrf(nsrue —
DEPARTMENT OP QUILDD\1C fNSPECTi01JS
212 Alain Strcct ' Municipal Building
Northampton, Mass. 01060
WOMCER'S CO'NIT ✓NSA'MN CISUR k -NCE AIt - AVI-l-
Qi ccusxJpertnittcc)
\,.,itb a ptzncipal place of businessfresidencc at: ---- -
(phone-'!)
ty/statr-/n P)
do hereby certify, under dic.pains and penalties of perjury:, :hat
O I am an employer providing the following iworlcer's comoensaoor. covem�e for Inv
etuplovecs wor Dog on t.iris job:
(lana -mac Coar ) (Policy Nu_ b-cr) --- (r:-pimrior, D2L.)
I am a sole proprietor, general contractor or omeowoer i:cie one) and have hired
the contractors listed below wbo have the folio%V"tg worker's cocoep_taDion policies:
lL+tllI2: Oi CO„� Ci0") (IR2ra11ct. CoInpan)-iPob i Nru1Il*C:) [1_\J1idRQ 1 bate)
(Na me of Coatraor)
(Name of Coa=clor)
(lnsurane: CompanvvPoum, Nuncer)
(Lasv-ranc: Company/%L-q- Nambzr)
(Name of Contractor) (Lasuran(-- Compa.ay/Poucy Numb,:)
(aW iLoca! nccct if occc --v to c, U'6c iaform -zioa pcta z ias to .11 cvo?-_c.o:-s)
( a sole proprietor and have no one worLdag for me.
() I am.a home owner performing all the work myself:
(Lxpiraion Date)
(Expo' 26ao Datc)
(Ecpim6oa Dare).
NOTE: ple:x be ewzm tt,,. Mj-je bemeo�vm Vto aamplay pcnc= to ciz = c=,—.=,w c rcpaa woric on a d.•ctl s of
aot more th_a tbro: tmfr in u-b3ch the bomoaw rcmda a oa ttx Vvuaca xpputcalz tbcu s. -r ooe C=�rlly oc=.daui w be
eitploc-t yun"---the ..a, -k r: � Pc=Lzi ea Act (GUI52.sa 1(3)), r-ppti boa bmoa
y a boma-f=: ties. a permit rr_y e-ideooc tLe
Icgal cL-tx- of ca c= loyx =der dao Wcck-0el Coazpaa� Az[-
uaderiypd tha a 00" of thi. — oaay be fore carded to Lb. iel Ae 4..(' OIL— or Lr—.,x oe foe th.
o°Ya'S` ^airai'°° and lhs C "W' to soauc t�ccii
ovSa under soa 23 A of htoL 132 c= led to the i ioa of aimiarl Pcaa-Wc
coauz mg of a fiat arup to S I.Soo.00 Lndrar iiap¢ iya of up to ooc y= sad aril pc o&rja in cbc room ora Slop Wort; Order and ■
finer of S 100.00 a dsy against tnc
. For dcp.rtaa�.i u.c only -
PcrMit Nt1IDt)Cr _
Signa n of Li crmittcc j
--fie 1,42 P., -- Lot K
SECTION 8 -CONSTRUCTION SERVICES
81 Licensed Construction Supervisor:
Name of License Holder
Not Applicable ❑
License Number
Address
Expiration Date
Signature Telephone
9�kTeatsiere�"C�orrr maEar�emerr`lr�€€`aritr"aEto
NotApplicable lcable ❑
PPi
Company Name
Registration Num er -- -- —
Address
Telephone
Expiration Date
SECTION 10- WORKERS"dOMPENSATIi
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.
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
}-LocMo
ng�Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature p r "�'�-
,.:
SECTION 5--DESCRIPTION OF" PROPOSED WORK (check;all applicable)
New House ❑
Addition ❑ ,
Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg.
Demolition ❑
New Signs [0] Decks [p Siding (0] Other [dj
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes �_ No Adding new bedroom Yes_ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
�0 � - s ., ., �." a - .. ! " w M ay;
66[ 41` W=�'ouse � 'Act iQ to�e�cs c�tar�s>I c� _�o�raCe�
a. Use of building: One Family Two Family Other
b. Number of rooms in each family unit: C Number of Bathrooms 2
c. Is there a garage attached? uV
/
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 L pfotc
s
I. Is 100 ft. Yes No. Is 100 floodplain Yes No
construction within of wetlands? construction within yr,
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 X
SECTION Ta - OW NER AUTHORIZATION" - TO BE COMPLETED; WHEN
BLDING.$ERMIT
OWNERS AGENT OR CONTRACTOR APPLIES.FOR UI
_�
UNA
as Owner of the subject
property
hereby authorize
ehalf, in all matters relative to qrk authorized by this building permit ap I ion.
l
`t�7712--
/
ignatureDate
o caner"
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 perju
Ll
nl•
Print Na
—,
ignature o Owner/Agent Date
Section 4. ZONING
All Informatihh 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
Side
Rear
L::_ RLIk-J
Izo20
ULA-2--, R:'= �(0-
E
L
Building Height
30
Bldg. Square Footage
T"
I i 0110i
Open Space Footage
(Lot area minus bldg & paved
parking)
I U F
�_ %
(p
�-
# of Parking Spaces
'—
Fill:
volume'& Location)
i�
I
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
N0 Q DONT KNOW YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW t17N YES 0
IF YES: enter Book Page? and/or Document #I i
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtainedQ Obtained Date Issued: i
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location: I
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 011 NO
I
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
City of NortF ampton
Building Department
212 Main Street
I "R"
Room 100 e b
Pj1 AY 1 1 2005 N6 hampton; MA 01060
phonel413-587-1240 Fax 413-587-1272
a':APPLIdk7WPC1t ZONJS CT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 2 - PROPERTY OWNERSHIPIAUTHORIZED'AGENT ,
2.1 Owner of Record:
�t a✓ G! t�, v..0-, �' F (�.�� C.i` I V G .1�1� x .. L " Lr
N ma a (Pri t)s Current Mailing Addre s:
Telephone
Signature
2.2 Authorized Agent:
5Pa*?2�
Name P . t) Current
Mailing Address:
Signature Telephone
SECTION 1- ESTI MATED'CONSTRUCTION COSTS
Item - Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building Ja) Building Permit Fee
2. Electrical ��' � ,, (b} Estimated Total Cost of
—H+ E"T Construction from (6)
3. Plumbing r\1 B
4. Mechanical (HVAC)
5. Fire Protection i
6. Total=(1+2+3+4+5) C
This'Sectiorr For Offc
Date ,
Building Permit`Number: tss'ued:,
Signature: r
i
Building.Commissioner/Inspector of Buildings
ng, Permit F.ee.
Number
Date
File # BP -2005-1124
APPLICANT/CONTACT PERSON BROWN WILLIAM W & HEATHER DRUCKER
ADDRESS/PHONE 113 NORTH MAPLE ST FLORENCE O 582-1334 O
PROPERTY LOCATION 113 NORTH MAPLE ST
MAP 17C PARCEL 037 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building,Plans Included:
Owner/ Statement or License
Z catc of Planc / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
IN_ FF ' 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 N� �-
ZONING BOARD PERMIT REQUIRED UNDER: § t;l 67
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 Co ssion
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.
113 NORTH MAPLE ST
BP -2005-1124
GIs #:
COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C - 037
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:
BUILDING PERMIT
Permit # BP -2005-1124
Proiect # IS -2005-1519
Est. Cost: $24000.00
Fee: $85.00
PERMISSION IS HEREBY GRANTED TO:
Const. Class:
Contractor: License:
Use Group:
Homeowner as Contractor
Lot Size(sg. ft.): 19471.32 Owner: BROWN WILLIAM W & HEATHER DRUCKER
Zoning: URB Applicant• BROWN WILLIAM W & HEATHER DRUCKER
AT. 113 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
113 NORTH MAPLE ST () 582-1334 ()
FLORENCEMA01062 ISSUED ON.5/19/05 0:00:00
TO PERFORM THE FOLLOWING WORK. -CONSTRUCT 22 X 26 ATT GARAGRONLY BE
GARAGE & NO LIVING SPACE)
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 $85.00
212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272
Building Commissioner - Anthony Patillo
10. Do any signs exist on the property? YES
IF YES, describe size, type and location:
x
NO
Are there any proposed changes to or additions of signs intended for the property? YES NO X
IF YES, describe size, type and location:
11. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common
plan of development that will disturb over 1 acre? YES NO � -
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
12. ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED DUE TO LACK OF INFORMATION
This column reserved
for use by the Building
7,
Lot Size
S4W
5
Vf
A
Frontage
Frontage
Setbacks Front
Side
L:R:4
L: R:
Rear
r It
1
Building Height
Building Square Footage
% Open Space: (lot area
minus building & paved
narkinn
—AAAA. 19—
*`
k Y
# of Loading Docks
Fill:
(volume & location)
13. Certification: I hereby certify that the information contained herein is true and accurate to the best of
my knowledge.
Date: U7711 la6 Applicant's Sigrii t
NOTE: Issuance of a zoning permit does not relieve an applicant's burden to comply with all zoning
requirements and obtain all required permits from the Board of Health, Conservation Commission,
Historic and Architectural Boards, Department of Public Works and other applicable permit granting
authorities.
W:\Documents\FORMS\original\Building-Inspector\Zoning-Permit-Application-passive.doc 8/4/2004
1
2
3
4
- --- - ------------
Name
---""___
File No.JV IJO
till information and return this form to the Building
I the $15 filing fee (check or money order) payable to the
City ofNorthampton
Name of Applicant: ( 1V-, ST�Z1fJ5--,, "d\ 1 ;7�,jAt<-' 1 ,Lmt n-2
Address: V-NQv4 1 }
Owner of Property:
Address: 3 5 �16�
�k
Status of Applicant: Owner _
Job Location: 1,5 11062
Contract Purchaser
Lessee Other (explain)
5. Existing Use of Structure/Property: -F'kTL ILi -'ik L -Tc -A�g_ i G\c i - 3
6. Description of Proposed Use/Work/Project/Occupation: (Use additional sheets if necessary):
Il j C'k �-i �Z %
M
7. Attached Plans: Sketch Plan Site Plan Engineered/Surveyed Plans
B. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT 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 #
9.Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained date issued:
(Form Continues On Other Side)
W:\Documents\FORMS\original\Buildinb Inspector\Zoning-Permit-Application-passive.doc 8/4/2004
"File # MP -2005-0139
APPLICANT/CONTACT PERSON TIM STOKES
ADDRESS/PHONE 20 TURKEY HILL RD (413) 587-9470
PROPERTY LOCATION 35 NORTH MAIN ST
MAP 17C PARCEL 252 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
�-` ENCLOSED REQUIRED DATE
Building Permit Filled out
Fee Paid
Typeof Construction: ZPA - PARKING RIGHTS
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved V Additional permits required (see below)
PLANNING BOARD PERMIT REQUIRED UNDER: § Q , .7� r3� oncl�gCe ►1
� C�
Intermediate Project : Site Plan AND/OR 1/ 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
Septic Approval Board of Health
Water Availability Sewer Availability
Permit from Conservation Commission
Permit from Elm Street ssion
Signature of Building Official
Well Water Potability Board of Health
Permit from CB Architecture Committee
Z2-3
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 the Office of
Planning & Development for more information.
taiiAi AMEACE
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JUN 2 2 2005
/7 e -3?
File # BP -2005-1124
APPLICANT/CONTACT PERSON BROWN WILLIAM W & HEATHER DRUCKER
ADDRESS/PHONE 113 NORTH MAPLE ST FLORENCE ()582-1334()
PROPERTY LOCATION 113 NORTH MAPLE ST
MAP 17C PARCEL 037 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Typeof Construction: CONSTRUCT 24 X 26 ATT GARAGRONLY BE GARAGE & NO LIVING SPACE)
New Construction ,41PP CA44 4 lti0" Yl as /" P(.P
Non Structural interior renovations Vy
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/ Statement or License
3 sets of Plans / Plot Plan
THE LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION 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
Septic Approval Board of Health
Water Availability Sewer Availability
Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission
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.
113 NORTH MAPLE ST BP -2005-1124
GIs #: COMMONWEALTH OF MASSACHUSETTS
MV:Block: 17C - 037 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category: BUILDING PERMIT
Permit # BP -2005-1124
Project # IS -2005-1519
Est. Cost: $24000.00
Fee: $85.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 19471.32 Owner: BROWN WILLIAM W & HEATHER DRUCKER
Zoning: URB Applicant: BROWN WILLIAM W & HEATHER DRUCKER
AT. 113 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
113 NORTH MAPLE ST O 582-1334 O
FLORENCEMA01062 ISSUED ON.5/19/05 0:00:00
TO PERFORM THE FOLLOWING WORK. -CONSTRUCT 24 X 26 ATT GARAGE(ONLY BE
GARAGE & NO LIVING SPACE)
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 SiLnature:
FeeTvpe: Date Paid: Amount:
Building 5/19/05 0:00:00 $85.00
212 Main Street, Phone (413) 587-1240, Fax: (413) 587-1272
Building Commissioner - Anthony Patillo