29-382 S�lP � w R «,w""►
Lx#y of 'Wart4atillpton s
1�1
51 -, DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building
North,urnpton, MA 01060 ,
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as its/her construction sup,::,-isor. 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 t secure the permits and inspections as
required can DELAY the project until such me as the proper p its and inspections are
madeCw-
I, S�?l"� c� aU G �' \ 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 �� b
Address of work �� �� c,
location (,
F w
o�i tw-r pro
I ,R� y @LLII�7 QI �L1Z:t1�c1111�1fOlt _
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.p DEPARTMEAfT OP BUILDrNC INSPECTIONS -
212 Alain Strcct ' Yfunicipal Building
Northampton, Mass. 01060
WORICCR'S COI�IIPENSATTON LNSURA-NCE AFFDDAVIT
%V LL a pri cipal place of busioess/residencc zt:
(sa�.11d rr/si.a.trla p)
do hereby certify, under dic.paLas and penalties of pcgw-y, h:r
r -
( ) I am an employer providing the followine worker's comocnsaaon coverage for my
eluptovices woriong on uiis job
i _:; (Insun�� Conr,�A) (Pctic:l�u_�ocr) (r:pir�tior, Dzr`}
O I am a sole proprietor, general contractor or homeowner (cic:e o:Re) and Lave hirea
the contractors Listed below wbo have the fok% iog workers cocoensa 'on pokiest
i -
(arnc Oi cont^cior) (1 t1R!1:1t1C,:, COIIID1r1}-rhGUC"i �`11Q1�C) -`"Jtill:Qi' l�.11C)
L,
i
(Name of Coommor) (lnsura.ncr- Comoan}vFolicr Date)
j (Name of Connaclo,) (Laa a.ncc CompanyfPolio• Namur) (Expiraoo Date)
;
i -
(Name of Contractor) (IosZlran Comcaay/Policy Numtrr) (Expirz6oa Darr).
(Mn,
{ ) I am a sole proprietor and have no one worlh-ng for me.
I am-a home owner performing all the work myself.
NOTE:plt=se be ewstc tli_bija bc==,v c ,uba employ pezom to ds c- c=--,=ao cr rcp.az work oa t d%—LL--C of
not mocc th_a Lbr- mrs is Wty6 the bomoowncr raids or oa the aatods zqpurtico:rl tbce -r ox Eoe-.11y cecrd=md to be
employes t, t thew S�.r,-=i. o-Act(GL151 S 1(5)).:;VG=.600 by a bommave fcr a lies-cc pcsmit >=y etiid one the
1 ct».,of ea to x
'� under ttao W �
Y ockc! Co¢gxm.t»n Act
1 p ad tba a oo7y of this eaiem�m m,y b<roe rd d to tsl� or r A�—d.e&OT,—or L--ro �.
covcrxlFc vciGc=1ioa=)d Uu r_-iltac to saxtrc Lovcrybc tmdcr soMioa 25A of MGL 152 as tmd a the i=,=s ioc of—iaal Pc-161=
coc :.its of n Gae orttp to sl}00.00—Z/Or orup to oa ye-•r end&,i)pcmrji ;a de roan of.Stop Work Ord,'nod,
fim oCS100.00.d_y tpia-A t>x
Fa dcp.rtn�u.c o ily
Permit NUML--7
- Y
1,4.71].". t.ol
Sil�z n f Li�sccJpcm-iucc e D -- )
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable'�1
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
� * Not Applicable .
9 Regis er`e Efam lmnrcxr�errfen Cow-ft y _ PP
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M-G:L.c.152,.525C(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...... Cl
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 oning Laws an Stat of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK check allapplicable)
New House ❑ Addition ❑ Replacement windows Alteration(s) ❑ Roofing ❑
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs (O] Decks (1771 Siding[0] Other
Brief Description of Proposed / �jQ V C l 5-T d
Work: ,
Alteration of existing bedroom Yes ,---'No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
a ifi e io�rs a ct fl ac l,tG"-
6 rrt x�sti r>ct`�iarzs rta co p ei� r a.ia l a:
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 C6nservation Compliance. __- Masscheck Energy Compliance form attached?
h. Type of construction
L 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 Ta-OWNER,AUTHORIZATION "TO BE'GOMPLETED.•--WHEN
OWNERS AGENTOF2 COK R-A APPLIES FOR;.BhJICDING PERMIT
1 as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this buildi permit application.
Signature of Owner Date
1 S�7the a Owner/ thorized
Agent heat the statements and information on the foregoing application are true and accurate,to the o my knowledge
and belie -
Signed uand penalties of perjury.Pr int for
N\
Signature of w Agent Date
Section 4. ZONING All Information 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 Front
Side L: R:: L: R:_ z
Rear
Building Height
Bldg. Square Footage %
}
Open Space Footage %(Lot area area minus bldg&paved I
parking)
E
#of Parking Spaces
Fill:
volume&Location)i.
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book ! Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
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 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES ® NO Q
IF YES, describe size, type and location: 3
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton Sat►sa ��i � � � �
t StAildin_g Department €Fdtrte' eat=
?`12 Main Street
Room 100
1 2u b NcwWampton, MA 01060 e a
phone 413-587-1240 Fax 413-587-1272Fan �
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: Thts;sectcorvtabe ccmp�eted byoffice
k
1 !
ap r dot Uutri
� �one ,Overla�Dcstrrct,
�E�4f Distcrc� =n .' ''"— C�IIfstxrc . ;-
SECTION 2-PROPERTY'OWNERSHIP{AUTHORIZED AGENT;
2.1 Owner of Record:
Sip C)v G- l b S►�GZa>r�yc � -�� 0/06 �-
Name(P'nt) Current Mailing Address:
Telephone S Cr_ 5.-
Signature
2.2 Authorized Accent:
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 ! �� orb (a)';Buiiding•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=0 +2+3+4+ 5) Check Number
This Section For Official Use Only
-
Building Permit:Number. Issued:
Signature:
Building Commissionerlinspectorof Buildings Date
16 BROOKWOOD DR BP-2007-0265
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-382 CITY OF NORTHAMPTON
Lot: -001
Permit: Bui din4
Category_ BUILDING PERMIT
Permit# BP-2007-0265
Project# JS-2007-000400
Est.Cost: $1200.00
Fee25_00 PERMISSION IS HEREBY GRANTED TO:
Const. C_las:;: Contractor: License:
Use Grog_ Homeowner as Contractor
Lot Sizes . et. : 10541.52 Owner: GOODENOUGH STEPHEN M&JUDITH
Zoning:URA Applicant: GOODENOUGH STEPHEN M & JUDITH
AT. 16 BRnr)V�A100D DR
Applicant Address: _ s Phone: Insurance:
FLORENCEMA01062 ISSUED ON.911112006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL PELLET STOVE
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:
rin l• Smoke: Final:171C "640-,-7
THIS PERMIT MAY BE REVOKED BY THE C TY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. _
Certificate of Occu anc Signature:
FeeType• Date Pa d: Amount:
Building 9/11/2006 0:00:00 $25.005706
212 Main Street,Phone(413)587-1240,Fax: (413) 587.1272
Building Commissioner-Anthony Patillo