29-307 (2) of Wort4ainptou
� � �lasaac3�usrtfs
DEPARTMENT OF BUILDDNIG INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building 1,
Northampton,MA 01060 ,
>r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 1083.4 to
act as l.is/her construction sups.:, _o.r. The state defines "Homeowner" as, "'Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fame
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 i,,egulations. 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, �A e:1 /4/4? old �a6 understand the above.
(Home owner/resident's sig ure requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work e,
location
I
�S,w•r nT ;..
ti Cri 3 of '.;o�fljalll�7fDll _
Q J E -gIX5.tchnscIIs -
—) —
w o DEPARTNIEI T OP DUILDr1\0 INSPECTION'S -
212 Alain Street INTunicipal DuddinE
Northampton, Mass. OIOGO
WORICE-R'S COiYTENSA`zIO.N MSURA-NCE Al, ,A.VI-j'
(Ii cz:usxJpermi flee)
«rlth a pru-lcipal plate of businessfresidence zt: --
(sar-t/ci ty/statcrri p)
do hereby certif-, under tlic.painS and penalties of pc -ury, --hat
( ) I am an employer providing the followinc- worker's comocnsa�on cove age for in)
etupiovices worL3ng on u>is job:
(Lasiu-snc Comp=y) (PcLi c:Nu--Aiy--r) -- (r:-pirz or,Dom)
( ) I am a sole proprietor, general cona-actor or homeowner (c cie one) and have hired
t-he conuactors listed below wbo have the foOoI-vine worker's cai nen_saaon pakies:
RNa c Oi CO:=C101 Grisurancc Cornpa,' -ill obC"i 01tc)
(N—C of C000I-2c10r) (InaLrancz ComDaIl}•/Pone~• N'L= r-O (Ex-Dis-z6on Date)
(Name of CColuracto:) (Ins1>,rancc Comma-nyf%Ucy Numb--r) (Expirsaoo Date)
(I zMc of Coatractar) (LnsuraIICv Compaay/Policy Nuab`r) (Expo-,doa Date)-
(ntxad't addli-�ocal xbcct ifncc �vw a�c�ucL�iafo2��oa pcviaias to.I7 occl-_.c.o:s) - -
{ ) I am a sole proprietor and have no one worL-ing for me.
I am.a home owner performing all the work myself.
NOTE:plesc be GAy:C Li M`. 'e hemrax�vm, .cT�lay pe-.ont Co L __ cs e�oa c rc;air work oa.d-< -Z of
ao(most than t'rw-.s in'-- cbL tb-bom-,1001 r=d.(x oa dt,gvjpl i LpqurtctL=tba o LT n0((,`^.-k:ay ocC^.d.-cd to L C
cnployc-s uoec the w. i;� Au(GUI 52-=1(5)),zpptioboa by a bomnoavc fc:_6�_or pcmit n_y c�id=—LL-c
IcVj nom-...or underdto Wo,+c .compom lion AcL
I uad-m-a d da-a copy*[a,;.cIItcoord oaay be f--.-dad to the O,.yertry�of lx-L.=rial Aoodeuj OM-of lrn—ror tho
coveaSc vaiGatioa n_'td the L-iJ—to scsauc'eovcrase under xciioo 23 A of MGL 152 can I d to the impca—of crimi pea+lti=
con=zeta of a fine or up to S 1 Soo.00.r dfcc im{siaoomal of up to 00-y=Lod aril pmaltin in be focm of a Stop Wort;O:d=Lod a
f=of S 100.00 a d_y ePita-A Mr-
Far only .
Permit Numtxs
Lot
i Lunt of Liccnscc/Pcrrrtiucc UBte -j
SECTION 8-CONSTRUCTION SERVICES {
81 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
S"Re4isfe°red Norrre"fmprci�ternerr Cott acd Not Applicable ❑
Company Name Registration um er ---"_
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSU' ANCE.AFFIDAVIT"(Ail G.L.c.1"52,".§25C(6)j"
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...... ❑
. :
D61111 NOW,
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-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"homeo t 11 certifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, e and Loca oning Laws and State of Massachusetts General Laws Annotated
Homeowner Signat e
i
SECTION-5-.DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑:- Replacement Windows Alteration(s) ❑ Roofing
Or Doors M
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [C] Siding[p] Other[O]
Brief Description of Proposed ,r / l
Work: 1
_ !� ,
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa Rfev�'ro�rseand a di ia�i to nsti> .hoi s>FC�;ca nCete ttie o owt
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.
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
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
Agent hereby declare thaf 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 aal t'es of perjury.
1 /ev
Print Na e
Signature f Vk edAgent Date
�
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 Fro
nt
Rear
Building Height
Bldg. Square Footage % i
Open Space Footage %
(Lot area minus bIdg&paved
#of Parking Spaces
(volume-&Location)
'
A. Has ie| Perm it/Vahanca/Fndi issued' x~~� �-\ �
K0 �� DON'T KNOW �� YES ��
|F YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO «_��
� DON'T nmuvv 0 ,"S
IF YES: enter Book Pug and/or Document#
��
B. Does the site contain a brook, body of water orwetlands? NO v�� DON'T KNOW «�� YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
`
Needs tobeobtained x~�` Obtained «r� Oau� Issued:
v�� �~� ' '
��
C. Do any signs exist on the proper�? YES �~� NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YE3 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb grading, or filling)over 1 acre orisd part ofo common plan
that will disturb over 1acre? YESK ) NO
`~, � »«�
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
a
City of Northampton
Building Department `
212 Main Street
Room 1.00 �e vatJa � � r
Northampton; MA 01060 �. s
phone 413-587-1240 Fax 413-587-1272 PPaVStt n ��
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1,-.SITE INFORMATION "
This sectron to be completecFbyoffice
1.1 Property Address:
���"f�r( j �j/ Lot ' Unit
Overlay Drstnct
EIQiiSti Oistr�ct _ GB DIStrICt..
SECTION -PROPERTY OWNERSHIP/AUTHORIZED AGENT, `
2.1 Owner of Record:
-Pn Arrp4e"e'l"c Pi,
Name(Print) Current ailing Address: �M 1i�
r 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 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
382 ACREBROOK DR BP-2005-0334
GIs#: COMMONWEALTH OF MASSACHUSETTS
"MM.Block:29-307 CITY OF NORTHAMPTON
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-2005-0334
Project# JS-2005-0440
Est.Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin Homeowner as Contractor
Lot Size(sa.ft.): 44300.52 Owner: NATALE JAMES F JR&CLAUDIA J
Zoning:URA Applicant. JAMES F JR & CLAUDIA J
AT. 382 ACREBROOK DR
Applicant Address: Phone: Insurance:
382 ACREBROOK DR (413) 586-0358 O
FLORENCEMA01062 ISSUED ON:9122104 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 9/22/04 0:00:00 8669 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo