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DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR '212 Main Street • Municipal Building
North,unPton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sup(::--,,:
;sor. 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 Ogulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings(before baekfill),
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
_ fi� ��_ 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
0 41 tth7•!pTO
F� yE U If�7 pf poriIla111P1011
4 DEPARTMEI-T OP BUILDr�G INSPEC710N
212 Train Strcct hfunicipal Duddinp —
Northampton, Mass. OIOGO
I
WORIC:R'S COi\ pENSATION MSURA-NCE AITMAVI-1-
i
1
(li txns�Jpermi tfcc)
v.11th a principal place of businessfresidence at: – -----
(phone-')
(STrC:z(/city/sutdap)
do hereby certify, under d.ic.pa_ins and penalties of pegury, .hat
( ) I am an employer providing the followine,worker's cotnocasz:J'o, covcmg.0 Ior Iny
etnplovecs Wofldng on this job:
(Insur-�c Corer o,) (PoLic i;t_�r�r) -- (r:-pirzdor, Dzl.) "
( ) I am a sole proprietor, general conn-aaor or homes' er (c' cie one) and have hired
the cono-actors listed below vgbo have the '000%vin2 worker's comoen_ta *on pobcies:
(c anoc of Con. [Moor) (Inst rant Cotnoan}-:1'obc,- NIUM_hcr) :�i,anon Datc)
- (Name of Contractor) (Las'urznc:. ComoanyiPo!im, Nu.mcrr) Ea_Ou-tion Date)
(Name of—Co=-aclo;) (Insurancz ComT=y[poU-q- N;rmb,_r) (Expir=aoo Daic)
(Nzme of Contractor) (Insurance Compaay/Policy Numb:.r) (Eapiraoa Date)-
(aQlC�l_d1i::-ocal�caif ncccv�•to ixx?u iafor=L..:ioo perU.iains to.i1
I am a sole proprietor and bave no one woridng for me.
( ) I am-a home owner performing all the work rnyseff.
NOTE:plcsc lx cwZrC tt,• µDC:]Kt, Jay P—� [O dO C• c -r oo c rryau WOt-c oa.d. U_,�of
in%-b a ttx bomoownc roid m«oa the pvund,z7purten_r_then os .1ty ocrsd.-_rod to be
eixploye-�unGc the�.u�;�p��Ace(GL'!S?,.n l(S)},:�piic�,poo by a 6omeoa�e fcr-lic5_a pcxmn cz:y e�idmec t>:e
Icgsi IL-t=of ea e=Ploy..r under dso Workola Coa,amatio¢Ad
I uada-nand d1,a a c-py of thi,mt mr�m,y bo foe-,.ordod to tho 0e9"t ooa or l.6 ,J nma=%Y OIL–or 1, ror tb.
cove�e'4 -!C lioa,Ltd th1 L•iliac to LO=M tovc = mac:I=j0Q 25A of MOL 152 eza ied to the iapnsiioo of cimiaal peailW(=
coa .mg of a fac orup to S 1}oo.00.zjoc impris�oCup to ooc yc_r=d aril pca.J'ua is tSc foe of a Stop Work Ordc and a
rim oCS100.00 a day tgtiast me
For 6cputtt+=�1 ux only -
F perm,NUm1--r
Lot n
Sit atu,of Liccnsce/pccmiuce � hip°--
f
SECTION 8-CONSTRUCTION SERVICES c,;
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9::1264 isfece`Horne lrii'coveniertoiiti^actor _ Not Applicable ❑
Company Name Registration um er - ---—
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L.c.1°52;§225C(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 1.08.3.5.1.
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 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 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
orthampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
omeowner Signature
r
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑- Replacement Windows Alteration(s) ❑ Roofing
r Or Doors D
R
Accessory Bldg. 1 Demolition ❑ New Signs [0] Decks (M Siding[pj Other[p]
Brief Work Description of Proposed ee CT— t e:� 2y
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a (f Hev haasea�d oi�adclix t oteAMAd Cov
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING 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 pain�pnd pErItJeS of perjury. '
Print tlarm6
C-7(
Signa ure of Owner/Agenr Date
`
v
Section 4. ZONING All Informat-i6h 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
RAKII
Ll
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume,&Location)
^
A. Has iu| ��it�han�R�i a�b� �����s�
' �~� x�� v�� �
�� �� DON'T KNOW �� �� ��
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO K J DDNTKNOVV 0 YES
IF YES: enter Book ! Page, and/or Document# |
'
�� ��
B. Does the site contain u brook, body of water orwetlands? NO v��� VV «_�� DON7KNO YES ���
IF YES, has a permit been or need to be obtained from the Conservation Commission?
`
Needs tobeobta/ned v�� Obta�ne� v�\ Dmto �ssumd.
�
�~� ^�� '
C. Do any signs exist un the property �� ��� YES �~� 0O �~�
|F YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO 0
=
IF YES, describe size, type and location:
E Will the construction activity disturb Qrading,excavation,or filling)over 1acre or is it part ofocommon plan
that will disturb over 1 acre? YESK~_~) NO � }
� `�/
|F YES,then a Northampton Storm Water Management Permit from the DPW is required
Cit f Northampton t��oPerrcti� r
y— i g Department , CewaaP°
Main Street sewedeptt mar xt �� �
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0100m 100a FVat�aylt � � s t '.
orti��ton; MA 01060 TuirSelsoStruclraiPla � }
T pb)prr 3-6 1 40 Fax 413-587-1272 fltotlS�te an w1w t
Af§E�OM Fa &TRUCT TER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
MATION
This section to be completed by office
1.1 Property Address:
a
_ _ �Nlap; Lot �Untt
Zone Overlay District
'04 oil Pw
IN. P,
Irri stDistrict �yCB D�stFict
SECTION 2=PROPERTY O ERSHIPfAUTHORIZED AGENT
2.1 Owner of Record:
Sex 6�� Y
Nam not Cur7nt Ma'i ddress:
a
Telephone
Signature /11 11
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)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) Check Number
This Section for Official Use Only
Date,
Building Permit Number-- Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
all
File#BP-2005-0435
APPLICANT/CONTACT PERSON SLOAT REXFORD K JR&NANCY R
ADDRESS/PHONE 47 CRESTVIEW DR FLORENCE
PROPERTY LOCATION 47 CRESTVIEW DR
MAP 29 PARCEL 462 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REPLACE 10 X 14 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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF CMATION 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 Co 'ssion 0(0//V/?-a 0
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.
47 CRESTVIEW PR BP-2005-0435
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-462 M CITY OF NORTHAMPTON
rr
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-2005-0435
Project# JS-2005-0579
Est.Cost: $2700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 10018.80 Owner: SLOAT REXFORD K JR&NANCY R
Zoning:URA Applicant: SLOAT REXFORD K JR & NANCY R
AT: 47 CRESTVIEW DR
Applicant Address: Phone: Insurance:
47 CRESTVIEW DR
FLORENCEMA01062 ISSUED ON:10121104 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE 10 X 14 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 10/21/04 0:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo