29-351 p�KNAMpTO 0({��
Clity of Xart4ainptart -
�IR'35RL}tlTB[tt5 -
-, DEPARTMENT OF BUILDIJG INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building
Northampton, 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 iris/her construction sups:-: 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.
cf �
(Home owner/resident's signat re requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
(11,if13 o �l'>tzzl��t7tr}�ftilt
��[3l ACII I75 Ct,3 =
L)EPART},1EN Of' EUILDI qG INSPECTIONS
212 Main Street ' Municipal Duildng j
Northampton, Mnss. 01060
WORKER'S COMTENI SATTON MURANCE ATFEDA, qT
_------------------------ -- (liccrs°Jcfrmitt;c} _ ------
�:iitll a principal place of busir�ess/residcnce
(pl:One -
dC) 11cI-c")y cCrLily; u 11,lcI die t?2i 1$ ?iiCl pC it 1t1C` Ol pCl�llf�t '..flitl_
I "am an emptoycr prO"'Iding the i011O'.ViI?L' '•:O1'ECrS 00111 )C11S8UOI] GOVCI::' C ?Or M)
('tnplovees Worldrlg on t?iis job:
(lnssian� Conran') clic,Nu nlxr) ---- (`r�.�,ir jon Date)
j I ar,z a sole proprietor, contr4C-,Or 110n1c101"YT) ;Ci:cic One) Pod, '1'12 -e aired
-s:th—, contractors listed beioNr;,+,o Ea t e .
('NamC of Contmctcr) (�AcL'-:7C l OIP.^":'iT;1 G11Cr 111iT i) L'?-; -n-cn, Datc)
(t jamP Of COIILT7CiQi) (7S1Su uP.0 (�0 �a;i�'/1�O 1Ci `tJI]CY i} ��:.'-:✓+' i7 G late)
(I,,'ame of Coancto- t { . ._. .,.... �. �, _ Datc
�) � �,s.slc.. _�,y �,�r'o1,�- nu�nl��r '�x;.�, a.��- '1
(Name of Contactor) -- (Tns, cane Com,=),!i'olicy Numrci) (Expi :tin- Da(c)
-_.-..::rr'.
i
( I rL11 a solL l?1 Oj?IlC Ji 2il1 i1a`. P.O Oi, U!�liiC! t0 -11
2111 a 1 omc
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not u�cte 1tL.ra Llu-oo utti'i i-,«j:;d:•wic k::.:-,�,•.�z,-r-j:<.-�a-oc;'`��.'_:._7 a_r._t:ci�r1 LhcC.o e:e n�<�-e�rsallY ccr.::i:::c�:o
ca1ployc3 u.'x':cr tiv wrxi"e-en cc - ; icn i r (Gi,1,2-- !(S:;' ;icn!,y a hocam �cr`•cr e L ez c ct per.
r.1:
legal onto;of Aa aarploy c<uaurr tLo Wor!ccrc l ocr^,wv.tion!.cL
I undc'ctaad diet z copy of a,-ctatcis'r_:ay to forti�,v�1oS to t'r,IYtxirt-x,cn:of Ir,dru:ri_7 Ac6r�'3't%Irioo of for Ux
oovcrmsc vrrificnEoc And tlLt f_ilurc to:n rc m��rM ur:dc::cc.icn 25A of MOM 152 can Icxi to tlx im{Osition of cr it l sl;:u
comuting of a flux of up to S 1,500.00 n:td'r i ::ui z c:!of::p to nr._}- e-.'l civil p-amities in l�fr,nn cf a
fire-of SI M,00 t diy tg!dtr:t Irr-
for ciq%zrux�'�tnl u.c caly'
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SECT30N 8 CONSTRUCTION SERVtCfS Ldl
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Reg s ire m 'mprouement Contractor-• Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTLON i0 WORKERS°CQMPENSATION INSURANCE AFFIDAVIT(M�G:L.,c. 152, §25Q5))
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...... ❑
III P
1:
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 fo-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-bocal Zoning Laws and State..of Massachusetts General Laws Annotated.
�s
Homeowner Signature O
'W
I
i
S"ECTICi1i' D O
PTIO NOFPRROSED�►VOk K ch
S �eckall a �licable
. - N
I
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ j Decks [ ] Siding[ ] Other
Brief Description of Proposed Work: la 'C"u— �EL--Vc
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll D- Sheet 0
6a. ew o a 'di'tion to ex"ithn; h uo srng; comp tfie fol ;owning:
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 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
SE fi(3TL WNE�Lt JORIZATI0N TO BE COMPLETED YIfHEN
OWNf S N �CC� ITRAGTOR p;PPUES FORBUILDING PERMIT
Cl-,A 5z:) �� ��c vt^'� as Owner of the subject property
hereby authorize to act on
my behalf, in atters relative tow ork authorized by this building permit application.
--7-
Signature of Owner Date
f,
Ex(�_N -) as as OwnerlAuthorized Agent
hereby declare th t the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the.gains and penalties of perjury.
Print Name
, f
4
Date
Signature of Owner/Agent ---
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
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413.587-1240 Fax 413-587-1272 t
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION S'- SITE;INFORMATION
This sec#�on�#o brt�comp eted6yaffice�
1.1 Property Address: v*.1
Map
(� Zone Overby strt '
EImStDisirj ct � *"
SECTION 2 PROPERTY OWNERSHIP,%AUTHORIZED!AGENT.
2.1 Owner of Record:
J
Name(Print):-, f Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTI0N:.3 ESTI1YIATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official use'Orily
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Elec.rical (b) ::r:timated 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.
Building Permit Number: Date Issued:
Signature:
Date
Building Commissioner/inspector of Buildings
r
40 AUSTIN CIR BP-2004-0182
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map_Block:29-351 CITY OF NORTHAMPTON
Lot:-001
Permit BUildinq
Category: BUILDING PERMIT
Permit# BP-2004-0182
Proiect# JS-2004-0268
Est. $Cost: $1800.00
Fee:Cost:
PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner, as Contractor
Lot Size(sg.ft.): 13590.72 Owner: BUSHEY RONALD J&LOUISA A
Zoning.URA Applicant. RONALD J & LOUISA A
AT. 40 AUSTIN CIR
Applicant Address: Phone: Insurance:
40 AUSTIN CIR
FLORENCEMA01062 ISSUED ON:8115103 0.00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WOOD PELLET STOVE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: oer v•°e: Meter:
Footings:
Rough: Rough: house# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final:
Smoke: Final:tj< f 0,31 .
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu an si nature: --
FeeTvne: Receipt No: Date Paid: Check No: Amount:
Building 8/15/03 0:00:00 3402 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo