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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 his/her construction supervisor. 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 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
v W,
,
-
g6 �lasaxchttsrtta'
DEPARTMENT OF BUILDLTjG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 ��
w0iucER'S COIYfPENSATTON INSURANCE AFFMAVTT
(Ii�nscrJfr•nnittec} --- -
%vith a principal place of business/residence at.
2qo R1v�eV-�r, � � I V&6cS t U t 03�
-
do hereby certify, under the pairs and penalties of perjury, that.
( ) i am an employer providing the followlil'4 •."'orr,c>'s cornpeasation coverage for my
employees working on this job:
0-n- ence CompaDy) (PoilCY Number) (Expiration Date)
O I ;2-no a sole proprietor, general contractor cr homeowner (chose one) and have hirers
the contractors listed below who have the folio i.:1 workers compensation policies:
(Name of Contractor) (Insurance- Com,,a ay/Polie; Number) (Expiration Datc)
(Name of Contractor) (Insurance ComDain,/Pohcy Number) (Expiration Date)
(ivtame of Contractor} (Insurance ComhautiiPo(icr Nulnlr�r) (Expiration Date)
(Name of Contractor) (Expiration Date)
ad itioel d r3xct ifnara 'to include a°oc nL oa p stn n rig sll c r,ra,_c:r )
X�iun a sole proprietor arld have no one ',vor4-Ing for me.
O I am a home owner performing all the wort: r-nys:�f.
NOTE:pte-.se ix a�rarc that A,�lc hocrxowixra«tio a'loy x to s to c.; ns r vZ c_n<:i x or repair work on a dwcl z of
not uKx-c tlLn throo units in N,;-Edl the hormoancr reaidcd cr ocl ttie &cnerally coeAidercd to be
CUtp(oy,3 un,ier the�voti a a cet:��z-lion Act(GI-152,7s1(5)),a{plizanc-n by a hoe-eow21Y for a l-mI a Perrin n ay eti�denae the
legal etatus of an omployor under the Wo(I tit Coen{xniation `.c_
I undaitsnd that a copy of this etate ;i mwy ba forwruciod to tbo 1?ctxir4l><xr1 of Ir�dlLl:ri al Acrij�,i�'Offioo o£lnwmw-for ttl
covcragt verification and than,failure to:r.cute covcrago undcx scctioa 25A of MOL 152 can Ir_d to the inaposi -of Work cs
cbasistin8 of a rtne of up to S 1,500.00 and/or iu1lu izoanxr t of up to cnc}tn erd av l penalties in dl fcxm of a Step
fu--of S I OO.W a day igaiml me
For only
''r Permit ritttnbcs
2--Z5=63 Iot
j Srgn't of Licanscc-Nermittcc
V
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : Q el��` Y1Q V� _ C) 1 0_7_9_7
License Number
Mass, o to3- - l iY toLl- ---
Address Expiration Date
i
Signature Telephone
9 'Re istered Home"Im 'ro"vement Contractor Not Applicable ❑
g p w. ... ,
_ / r t aAle�
Company Name Registration Number
ZqO f2,kVer bra � ee���{ �SS� 61c)33- o
AddressssJ� �u 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......' IVf� CY'M1 e'er
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 f(:-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
s
SECTION 5- DESCRIPTION PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ l New Signs [ ) Decks [ ] nSiding [ ] Other [ ]
Brief Description of Proposed Work: �GiY`I �f� _ I`ev��� v� Si��y►���� I�GiS�Y►�zYt�J 1`(e� _
Alteration of existing bedroom Yes X No Adding new bedroom_ Yes No
Attached Narrative ❑ Renovating unfinished basement _ —Yes _ No
Plans Attached Roll ❑ - Sheet
sa:°If'New house antl br='addition'to existiny housinf , complete':the following:
a. Use of building : One Family _ Two Family Other
b. Number of rooms in each family unit:—. _ Num')er 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. N'lascheck Energy Compliance form attached? _
In. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain __Yes_ Nc
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 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize !M�` 1\�S�R _ __ _ _ _ to ac o
my behalf, in all matters rebative to work authorized by this building permit application.
Signature of wner Date
I, '.f�p '�` ��,SC�y►�V1 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 d penalties of perjury.
_ I ► ��� ------
Print Name
c�-3 ----
Signature of 0 ner/Agent Date
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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
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
IF-YES, describe size, type and location:_ __
City of Northampton Status of Permit
- Budding Department Cub Cut /Drlvewa.,
212 Main Street ScvWer/Septiiq. ailab
Room 100 Water/Well Ava
Northampton, MA 01060 tr Rural-Parks _ x
j phone 413'587-11240 Fax 413-581 1272 Plot/Site Pla`n�s
Other Specrfy"'« ��E" � Sa
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
- This section to be completed by office
].1 _P_rope_rty A__ddress:
Map_ Lot Unit
,firs 6 0 0(0 Zone Overlay District
,I V
Elm St. District_ __ CB District___-__
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
I
wner_of Record:
Nsm�,:!Dr'in , went Maier g.A dress:
i
r _
Sid nature
2.2A_orized Agent_
i
Name(Print) ('-,:rrent Mailing Address.
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
tem Estimated Cost (Dollars) to be Official Use Only
_
—completed by ermit applicant
1 B'widing f �_�C-)� O v I (a) Building Permit Fee
12 Flec.rical (b) r.�timated Total Cost of
Construction from (6)
3 Pi!ambing [Building Permit Fee
_ I
4 Mechanical (HVAC)
5_ Fire Protection
E_ Total_= 0 + 2 + 3 + 4 + 5) _ -- - Check Number
This Section For Official Use Only_
Building Permit Number: -_._ Date Issued:_ —_ ---
Signature: _ —------------ - - -
Building Commissioner/Inspector of Buildings __ Date
op
. . 44
File#BP-2003-0723
APPLICANT/CONTACT PERSON Matthew Rasanen
ADDRESS/PHONE 240 River Dr (413)584-0045
PROPERTY LOCATION 31 GREGORY LANE
MAP 29 PAWCEL 527 001 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: PARTIAL REMODELING OF BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 010787
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INNF� ATION 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 ommission
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.
BP-2003-0723
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: fticrtmq
Category: BUILDING PERMIT
Permit# BP-2003-0723
Project# IS-2003-1174
Est.Cost: $5000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Matthew Rasanen 010787
Lot size(sg.ft.): 6098.40 Owner: LAVENTIS GERI
Zoning URA Applicant: Matthew Rasanen
AT. 31 GREGORY LANE
Applicant Address: Phone: Insurance:
240 River Dr (413) 584-0045
HADLEYMA01035-9641 ISSUED ON:3110103 0:00:00
TO PERFORM THE FOLLOWING WORK.-PARTIAL REMODELING OF BASEMENT
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 3/10/03 0:00:00 7866 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
3
Lb
1
oar-
wca
&
File#BP-2003-0723 y
APPLICANT/CONTACT PERSON Matthew Rasanen
ADDRESS/PHONE 240 River Dr (413)584-0045
PROPERTY LO
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: PARTIAL REMODELING OF BASEMENT= ;'ADD P PATIO
P� '
New Construction
Non Structural interior renovations
Addition to Existing
Accesso1y Structure
Building Plans Included:
Owner/Statement or License 010787
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 Str Commission
Signature of Building Of icial 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.