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�., DEPARTMENT OF BUILDING INSPECTIONS /
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INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
4
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/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 rouLrh 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, 2 understand the above.
(Home owner/re de is 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
ti
A d Fs�cssrtcE}usctts' � 5
m UEPAIRTNfENI• Of' £UILDI?�G INSPECTIONS
212 Drain Street ' Municipal Buil(UlIg y
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE AF MAVU
v,,Ith a principal place of business/renidence t:
(phone-1 --
do hereby CCrlu}; LI]a d]e Daills 3i](j pC it 1tICS Oi pe�l!Il, :hat.
O I am an employer providing the follo•,v;t]t .:orr_crs Colnpcnsation covert:Jc tor my
el> ployees working on this job:
(InsLranG Coiapam,) (=e;ic,hrt Lai ber) --- (Exp;r,:dori Date)
( ) I a.cl a sole proprietor, conircror o: homeowce: (circle one) and 'gave hired
the COn%iactors h$ted be.ov'r; 'ho h2.-, tht COu
(Name Of COntraClGr) 1:L'i....',1C LGIn^ i<<�Ol1Cj �11ZTlr) (E7:.
(Name of Contractor) -- (717sJr=nce Comp-,ay+'Pohcy Nurncrr) (F,>:ririioa Date)
(Name of Contractor) l;at
,
u; �yiPol t'un_r r )
- (Name of Contnctor) —- (Insurance Comr_yiPolicy Numb-r) - (.H,4ni-:no' Dare)
i
l- ) i <ur] a sole prol>ric.ur ��_:.;i have no one .�,ors I� fo,,- -mc.
aiIl < llonle Owile. i)Ci:: `I??1I1 '?ll ,_. v... ,:,
NO"I-f= ptc-sc to awuzc tt:>_ =,P
not:mce th_a throe vni+s
ca*.aioyc3 uti-,cr t}r tvc:{: s cc x-�::im Fs ((ri.!S2� !(5);•a,:, °;:ia:by a hor-iON-cr for e cc c cc p-r.',:i:
legal etatue of nn aCxployx ucu:er tL•n Wockce'&io ;orn,ti m!.cL
I undo.-stand thy:a copy olltu.ctatc:sl ruy bo forw.vcS to tl»CYji %—e of lode ri-J Chao of for tlx
covcngc vc:jEcz ion and t!`--t r:jl to:n c corm ur3: c�,iM 25A of MG1,152 can lc--d to tlx in7lWSili Y i I PRA
—i-stmg of a fine of up to S l�0 .00 m; 'Ct t^:;:ri xz',-:1 of::p to c } e:.i civil xru2lin in do irnn of a S!�, ;Jni }d 3
Lrm oC S 100.00 s dsy a��.in.l m..
Fcr dg;uuznial urc c.ily
Pcrrnit NXIMIX r -—----- ----
�,nacurc t�f i.iccnr tJl'ctm;ar� •�'+�
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SECTION 8-::CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
Reg 5 ere ome mproeme tContractor Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTIOIJ 10 WORKERS' CO INSU
MPENSATIQN RANCExAFFIDAVIT(M.G:L, 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 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 Local Zoning Laws and tate of Massachusetts General Laws Annotated.
Homeowner Signature
s
SEGT ON5DESC tP7�ONOFP-ROPOSED WORK(check�ll apgl�cable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding[ Other [ )
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
a
RN to is: s tid or��:c�d�.tion to exist�n�housing;�catnple e to he�follawin�:
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
SECT01VO�NERAI7THORIZATION TO'BE COMPLETED inwH EN
OWNEkAGENTOR CONTRACTOR APPLIES, FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize to acT on
my behal , in all matters relative work authorized by this wilding permit application.
Signature of Owner Date U -a
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
Signature of Owner/Agent Date
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 °o
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 DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT 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
lorthampton, MA 01060 i :
E'
phone 413-5,87-1240 Fax 413-587-1272 .
STS
- v
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE-INFORMATION
This secl ion to be coxnpletecl by office
1.1 Property Address:
/i'199 , d/D 6 .� �k �e�lay lf�sti�ct�
SECTION-2-PROPERTY-OWNERS14 P/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address: (J53
Telephone
Signa re U 3
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)I,Estimated_Total Cost of
Construction from 6
3. Plumbing Building Penmit'Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2+3 +4+ 5) Check Number
This Section.For Official Use Ortl
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
81 SANDY HILL RD BP-2004-0640
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-407 CITY OF NORTHAMPTON
Lot: -001
Permit: BUil ft
Category: BUILDING PERMIT
Permit# BP-2004-0640
Project# 001541004-0908
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 20821.68 Owner: JONES LAWRENCE
zoning URA Applicant: JONES LAWRENCE
AT. 81 SANDY HILL RD
Applicant Address: Phone: Insurance:
86 FLORENCE RD
FLORENCEMA01062 ISSUED ON.1211103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WOODSTOVE
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•®W J a-,q-0 L_
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT N OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeTvpe• Receipt No: Date Paid: Check No: Amount:
Building 12/1/03 0:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo