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DEPARTMENT OF BUILDING INSPECTIONS
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 has/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 w ilts any person(s) who seek to
use the home owner exemption, to act as their own c struction supervisor, to be aware
that by doing you become responsible for com iance with state building codes
and regulation . The inspection process require that the building department be called
to inspect work at ious stages, which inclu foundation/footings (before backfill),
sonotube holes (before our a rou h bui in ins ection before work is
concealed insulation s ection if re u' ed and a final buildin inspection. The
building department requ\is these inspec ons before the work is concealed, failure to
secure these inspect ions resul t in f ilure to obtain a certificate of occupancy
until the work can be ins ec d.
If the homeowner hires other tra s to erform work(electrical, plumbing& gas) the
homeowner will be responsible to e sure that the trades hired secure their proper
permits in conjunction to the buildin ermit issued, and that they get their required
inspections. Failure of the individu tr es to secure the permits and inspections as
required can DELAY the project u til su time as the proper permits and inspections are
made
I, understand the above.
(Home owner/resident's sig ature requesting emption)
I will call to schedule all required uilding inspections cessary for the building permit
issued to me.
Date
Address of work
location
z° a 0
F E 5T 3 of
PJ E 11s-sarhacr!!a' _
DEPARTT.TENT OP BUILD010 INSPECTION'S
212 Main Strcet Dlunicipal Building
Nlorthampton, Mass. OlOGO
RIQ:IZ'S 1fPENSA_nON MSURAhCE AI'rU)A��IZ'
(li ccusxJper mi ttce)
\vith a pri cipal place of business/residence at:
� (sa�tic�ty/slaic�ri p)
do hereby e under the. --ins and cnalt�es of e :hai
Y '�`, p p p '��`�: `
( ) I arm an employer providing the follo.ving worker's compcns��on cove age or my
elvployces worlong on tsiis job:
j
CLamr== COM=.m') (Pt lic: u.-Lb-cr) FExpiruon Dzt_.)
!, O I am a sole proprietor, general conrracxor or homeow-Der (c cie one) and have hired
the conua(nors listed below wbo h2ve the follo%viog worker's ramoert_s26on policies:
+fl17Jc or C0 r-CiO") (IARlr]ItIC C01T1017}'/PGUCi NIL1i71={:) �I_tiJliJliO Datc)
(Name of Contractor) (lnsarancz ComoazwPoUc Nun-^r) (L�vu uon Date)
(Name of Coamcto:) Omsurancc Compare}-/Polio-Nwmbe.r) (E%piraoo Date)
(Name of Coamactor) (Insurance Compzanylpolicy Numbs) kSpi,,ati Dafc) .
(atascb
=U4-- C1J tSca.ifnCC=: ry-to infor�oa pCtaiaimc to.0 000r--c.o:-a)
I am a sole proprietor and have no one wori;dDg for me.
( ) I am.a home oNvoer performing all Lbe work myself.
NOTE:plan c be-wart tb:wt:Je bomco,,r-v bo employ p--:,O=io do
—,= cs L oo e rcp2ff-ark w r d`.clL^Z of
act wort thm aTc-tmrx in u'ycb the botnoowact resido or oa the p-oua z7puunrs tbceo� o0(U-ae-.Ity ocrsd w be
employ--unCc the kui;a'-ate*—.—.*;oa Aa(GL152=1(5)),zppttasioa by s homeoa ua f=:4=—-a P=Mt r=Y e%zdmcc LtC
legal n ,,,or nn =Playa under dare W.'kaes CV tioo Ad
i undcsaaad lb-a Dopy oI thin maa may be forte nrdaE to the Dgq, mt of ka—Iar th.
cOvcx'& c Yeif cmioo and Uu Lilts-to sonar-to�ernsc trader soetion 21A of htoL t 52 can led to the t��osa-oa of criminal pcailtiCo
C=;=i=zofx aaoc of up to s I}oo.00&nNcx orup to Doc y.=r tnd-Nil prn+hia is CbC form o(a Ssop Work(Drda sod a
ram of S 100.00 a d_y tpiaa me
For dcy.rts=>J use only
Pcrmlt 1`lumb=
Lot .
DG' � p�-- Lot
I9=turc of Li Crmittcc j
4 ♦ • �
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable�j❑
Name of License Holder: � ��/dr �5 K
License Number
Address Expi do Date
Signature Telephone
�wwurwar-
Corrivany NotA licable .❑
PP Name Regis ration Number
S}} &1)
Address Expiration Date
Telephone �-�oy`Z
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL.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...... ❑
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 Rdition Section 108.3.5.1.
Definition of Homeowner:Person%MO'y 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 dwelling,attached or detac structures accessory to such use and/or farm
structures.A person who constructhan one home in a -vear period shall not be considered a homeowner.
Such"homeowner"shall submit to the Buil 'ng Official,on orm acceptable to the Building Official,that he/she shall be
responsible for all such work performed u er the b din permit.
As acting Construction Supervisor your pres a the job site will be required from.time to time,during and upon
completion of the work for which this permit is' ed.
Also be advised that with reference to Ch 152 orkers'Compensation) and Chapter 153 (Liability of Employers to
Employees for injuries not resulting in ath)of the achusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you un r this permit.
The undersigned"homeowner"c 'fies and assumes responsi 't ompliance with the State Building Code,City of
Northampton Ordinances,Stat and Local Zoning Laws and Statssachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[O] Other[EI]
Brief Description of Proposed i
Work: [ 4/�leL L,*Y0/,__ 2-S S 811f,�p04CI OA-C""
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
z�dn.�`
sa� fNewo�ls "arid�racdifion#o Qxls#ing housincl.cOmaiee �ilwma:
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-OWNERAUTHOR_1ZATION-TO BE COMPLETED'WHEN
OWNERS AGENT OR CONTRACTOR APPLIES.,f.OR BUILDING PERMIT
as Owner of the subject
/c°l
property
hereby authorize _
to act on m be in all mrelative o work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized
gen' reby Zeeklare tha�atements nd i nformation on the foregoing application are true and accurate,to the best of my knowledge
an belief.
Signed under the pains and penalties of perjury.
Print Na e
Signature of Owner/. en Date
� ^ . .
, �
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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 i
Rear
Building Height
Bldg.Square Footage % r-
Open Space Footage %
(L.ot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Variunne/Findi ever been issued for/on the site?
�� YES ����
NO �~�� DON70NOVV �~��
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds? '
NO � y DON'T KNOW YES~�
IF YES:� entor Bonk ' Pogo! and/or Document#|
(
'
»�� �~�
B. Does the site contain o brook, body of water orwetlands? NO �~��~� VV �~�DON7KNO YES �_�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobaobtained v��Obtained Oote |ssumd'
�_� ' . .
C. Du 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 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb grading m filling)over 1 acre mis it part ofocommon plan
thaw0disturbovor1eore? YES ���� NO � )
|F YES,then a Northampton Storm Water Management Permit from the DPW iorequired.
`
a
wH
City of Northampton � �
��ilding Department
12 Main Street r t t s
Room 100
ampton, MA 01060 zKKKK
i MAY p e 41, = 7-1240 Fax 413-587-1272
31111
,.
n`APh1CAfiidis FISTRU T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Thissection to be�compfefed by office "
1.1 Property Address:
Maw mot Urnt
(,
� �
Zone Overlay District
�n
lin t DiStnCt GB�JStridt
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: /� f
Name(Print) Current Mailing Address:
Telephone
Signature 16
2.2 Au orized Agent:
�� oo���� � �
Name(Print) Current Mailing Address:
Signature J Telephone
SECTION 3 ESTIMATED'CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
com Ieted b rmit applicant
1. Building (a)'•Building.Permit'Fee
2. Electrical C (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 Comm issionerllnspector of Buildings Date
M f
BP-2006-1309
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-1309
Project# JS-2006-1934
Est. Cost: $651.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sg.ft.): 18817.92 Owner: ROWLEY WILLIAM R&
Zoning: URA Applicant: DE Sheppard Roofing
AT: 43 BROOKWOOD DR
Applicant Address: Phone: Insurance:
224 BERKSHIRE TRAIL (413) 587-0092 Q
CUMMINGTONMA01026 ISSUED ON.61112006 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE REAR PORCH OVER 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: Date Paid: Amount:
Building 6/1/2006 0:00:00 $25.00896
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo