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5i DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building
N«rthamp(on, 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 !Js/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 hvo 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
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
IL/1r11
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OF FUNDING
212 Main Street ' Municipal Bultdilli,
Northampton, Mass. 01060
C'O-Nl-PFl,,SATl0i'-,' INSURANCY AFFIDAVIT
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SECTION 8 .CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : _____
License Number
Address Expiration Date
Signature Telephone
�, -... 4 - .. � ���, 41 Not Applicable ❑
a�.�. „,. .$
Re�i�tered�Flo e1�'nprwem`e`rit�Conttactor ,�, ...��.�e
Company Name Registration Number
Address Expiration Date
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...... ❑
11.� � �oxne ®�w�nerEgeinptton
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 fe-which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 ;L,iabiht} of Employers to
Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, VOL' 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 Low i1 7 Wing Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature `��'
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SECTION 5 DESCRIPTION'iOF-PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other I]
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❑
sa_:IUNevi%houses and"or a ddition'to`existing hdUsin comp1eteah&J611owinir:
a. Use of building : One Family a 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. Mascheck 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-"OWN'ER:AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
l
as Owner of the subject propert
hereby authorize _ __ to ac; or
my behalf, in all matters relative to work authorized by th;s 'ouilding permit application.
Signature of Owner Date
as Owner/.Authorized Agent
hereby 9clare 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 p/ena�lties,of perjury.
/�1L!1✓ ------ --- -- — ----
Print Name
Signature of Owner/Agent Date
k.a
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 /- 93 ')
Frontage /2 -5
Setbacks Front /00
c
Side L: R: L:ZC R: 7
Rear
Building Height kA n
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces Ns r— 147f
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ✓ DON'T 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 #
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:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No V
IF YES, describe size, type and location: _ ___
City of Northampton
Building Department
212 Main Street 5 ,Se .f
Room 100
Northampton, MA 01060 7 Sets e `
phone 413-587.1240 Fax 413-587-1272 P►o/Site Pia6
APPLICATION TO CONSTRUCT, ALTER, REPA C , N A Or t OR TWO FAMILY DWELLING `
SECTION 1 - SITE INFORMATION
1.1 Pro eP rty Address: p �, ��,3 t ec ' be, ompleted by,office
Map "� LotX �, A'nit
`7 �fcl J
lej
rn Zone Overla bare.nce— y�Distrtct9
Elm St-District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) C yr, M il Addr ss:
Telephone
Signature
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 permit app icant
1. Building � � ,�/� (a) Building Permit Fee
2. Ele:irical _ (b) timated Total Cost of
Construction from 6
3. Plumbing -----._,� _ - — ---�--- - -
— g — — `— `— -- I Building Permit Fee
4. Mechanic-3! (HVAC) J
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) CJ i Check Number
This Section For Official Use Only
Building Permit Number: / Date Issued:
Signature: -_
Building Commissioner/Inspector of Buildings Date
BPr
-2004-0027 7
APPLICANT/CONTACT PERSON BRIN MICHAEL F
ADDRESS/PHONE 601 BURTS PIT RD (413)584-5159 Q
PROPERTY LOCATION 601 BURTS PIT RD
MAP 29 PARCEL 477 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out a 44
Fee Paid
Typeof Construction: INSTALL 24'ABOVE GROUND POOL
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
INF9XMATION 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 ' sion
0 00
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.
601 rs PIT RD BP-2004-0027
COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: BuiidinQ
Category: BUILDING PERMIT
Permit# BP-2004-0027
Project# IS-2004-0044
Est. Cost: $1400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 79714.80 Owner: BRIM MICHAEL F
Zoninp-: SR Applicant. BRIN MICHAEL F
AT: 601 BURTS PIT RD
Applicant Address: Phone: Insurance:
601 BURTS PIT RD (413) 584-5150 O
FLORENCEMA01062 ISSUED ON.7114103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 24' ABOVE GROUND 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 Occupangy Occupancy Signature:
Feel e: Receipt No: Date Paid: Check No: Amount:
Building 7/14/03 0:00:00 1348 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo