29-554 O O
� e Critg of Wart4amptan
w Z
�ASSAC{�IISCttS
d DEPARTMENT OF BUILDING INSPECTIONS wEr
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 iris/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 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
.�tinx rT
�, � (1•if�T >,if ��tT�-tl��tltt}�fc�tl f`(,Jr�_I' �.
^� DEPARTMENT OI' LUILDT?�G INSPECTIONS
:m
212 Main Street Municipnl Iluilding j
North amp toll, Mars. 01060
WOMCER'S COMTENSATION 1NSURANCE AIrFIDANriT
(lic�rs^Jcflmitt�^) ___-_--
NvIll] a principal place of busiressJrc: denc
(phcnc.'=;
--------- (StrceUcitiG
do hereby cer Lif•,-, una�r the p<rls ,end pe,l itics oi�per}ury, that_ -
I affil an employer providing the 1011ov'"MQ '•:OI t:C11$ coIi]t>CI]sat101] GOVCI't:"C for my
employees working on dies job:
(Ills u== Comte') (P c�;c.Number) ----- (F�.F•ir.:doa Datc)
j I am a sole proprietor, general contmctor hor,:efl:voer (circle one) anc' 't;a,e hired
th-1 contractors 11ste., be.ov.,« 0 i--vc the vi oFke'js CO �e]1Stu0i1 "0!l :cS:
(1`:=c Of Conl'mctor) (L R,:,=-lc CGIP. ".:itiPGl]C{ N111T1)vi) i?'- .+.IG': Date)
(Name of Conn,cto.) -- (I'm7u _ace (Ei,7 iron.Date)
(2"'amc of Contractor) — (L71StI 3I]C� L Oi :? .i/i�OL'�: Nufl?ii r) X.i;:[1. Dal,--)
- (Name of Contactor) —- (Ilia ranc Coln^�;},/Policy ivtum��*) fI;: i-:uG- Dare)
^.t1.lGi.`.41�l:1 OC:1I S:::r{:�::!..•�..a,.:.,�.�..}...:. .-•:—K:':a::�Y: —._.... — eli!`:(:::_:�;:"�
( ) I ml it :;ole prclpllet")`" i1 1Q hLtVc v '. ,l !' fp- °
/Y,�v il0 Oi1C 'i, �.:ii; 1 :i_`-.
11i11 2 home o`Vi1C U 1 `"1i11ii y
*:OTE.:plcsc tc ntiwc tt:>:.t ilc lx<;co tir ro r.plc ;.—c tz.a> :c,:air
not umc th n throo uui+i i ttt dt he l; ��.:tZr rc: t or o; n.<t;crlall•;C,:,n1 rr, F1
ealployc3 ur)''r t}r i+r GL.5 );, e: lry hat im t w:`or n i e et p:r::i:: _'tir,,e 4._
�5' •l:,:xz:
legal ctatuc of an amplo)•er under thn Wo i clt Co,-t.;.o jjon!.cf-
I undeztaad th,< a cmy of thi„rtmt--: --n:.y ho to tI»Irtivrtzrn:of It>dz>.stri el/ �ls'�Cf moo of 1:::+."_a for tlx
aovcngc vQ-ilictioo and th:.t f ulwu to t.1.tr_ 25A of MG1,152 can Ir_d to tlx i-1-16-cf r i:_l petal:.=
oomistatg of a Im-of up to S 1.500.00 n:t:V or i^tnri:xZti:1 of::p to rr� }- r.-.j evil xrutt a in 1-4 1i-,rtn Of n Sir., y'ni.On;=_r,;1 a
fittz of:;I 00.W ►cisy gain:.m. .
Fur dq;uutti�tsl u.e only
—T---- � " Y 1 Pcrrnit Ntimb::r j
5i nature cif i,iccn:cJPcrnuitc:
SECT ON 8 CONS�RUCTIGN SERVICES 1
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
Reg s ere orn mprovement °ontracto 1,02M Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
$x
EG_.TN0R , . c 152, 25CEM
_ 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 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 Massachusetts General Laws Annotated.
Homeowner Signature
SEGT�;O - S Ot? dAAOPOSED1WORK� check i a I�caUle 27.
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs jt Decks [ ] Siding i ) Other [ ]
Brief Description of Proposed Work
AIteration of existing bedroom Yes No Adding new bedroom Yes No
ttached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll O- Sheet❑
a. fl tl'tion to ezisting�h u�s ng, w ip a _' EIROM:
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. 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 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
ECTFF� EROTOf31ZAT4 ON TO BE COMPLETED WHEN
ONTR�CTOR,APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property
hereby authorize to ac; 01
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 pains and penalties of perjury.
Print Name ` f°
Wv V
Signature Owner/A Date
ot
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:
Ab
'ty of Northampton
L ^n ilding Department
L� --- ----`1 212 Main Street
1 Room 100
t
2 0 2003 t ampton, MA 01060
phone 4 3.5 7.1240 Fax 413.587-1272
rrT ��IlIti11NG tNSF�CTI�"fS
ONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SBCTION i!- SITE t,NF04?,.T10N
1.1 Property Address: Thssec#i+o "'deb. fftcek'
z :
SECTION 2;- PROPERT=Y"OWNERSHIP/AUTHORIZED AGENT
2.1.Owner of Record:
Nam (Print) Current Mailing dress:
i A )) �- ' �� Telephone
ignature (�
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCT.ION..CQSTS
Item Estimated Cost(Dollars)to be Official Use'Oniy
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Elec.rical (b) 'Estimated Total'Cost of
Construction from 5
3 Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection I!
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building=Permit Number: : Tate:lssued:
Stgnatvre: ,
Building Commissioner%Inspector of Buildings„ Date
INN6RD
BP-2004-0200
GIS#: COMMONWEALTH OF MASSACHUSETTS
Iap:Block:29.554 t CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0200
Project# JS-2004-0295
Est. Cost: $3500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 19994.04 Owner: CHAN WILLIAM T&HIGY WAN
Zoning.URA Applicant: CHAN WILLIAM T & HIGY WAN
AT. 385 RYAN RD
Applicant Address: Phone: Insurance:
385 RYAN RD
FLORENCEMA01062 ISSUED ON:8120103 0:00:00
TO PERFORM THE FOLLOWING WORK.SHINGLE ROOF OVER EXISTING 1 LAYER
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 8/20/03 0:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
NNOW