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DEPARTMENT OF BUILDITjG INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building 5
Nortluaripton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as i:is/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 fami
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 0gulations. 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
}1 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. l
Date
Address of work
location
r
„� E cT f Pf[]tt �arf(jlll}�toli _ _=
9 r � 1l i3iRrll[SL[1l0• _
a DEPARTMEI-T OP BUILDD\IG INSPECrioll's —
212 Main Strcct ' DSunicipal Duddin0
Northampton, Mass. 01060
tip'OIU<3:.R'S COi\UENSATION LEISURANCE Al<' , A.Nrj-j.
(]i ccns�Jpermi tfcc)
v.rilh a pn-icipal place of business residence at: — -
(phone.")
(sn ty/statc ap)
do hereby certify, under dic.pain5 and penalties of perJury, hai
( ) I am an employer providing the followe
in ''xvorkcr's comocnsarion cove2gc for in)
elnplovees wortorlg on 0115 job:
(In an=CoEipam,) (PcLic:Neu_= __r) --- (r:piraaor, Day.)
O I am a sole propr;etor, general contractor or homeowner (ci tie one) and have hired
Che coon-actors listed below who leave the `ollo�v' P worker's cacoen_saaon pakies:
('Namc of Contncior) colnp3n)-lout-i 1111c)
(Name of Coo c cior) ons-d=c:, C-omg Lav pout' \LMbcr) (-txoir,:iion Date)
(Name of Coaraao,-) Ozswanc; Compare}•/PoUcy N,.mbJ) (Exoirtioo Daic)
(Name of Contractor) (Losuranc-c Company/PoUcy Numbs) (Expi-zdoa Datc).
dxci,if to c=hx iafocn=�oc peryunins Lo.0 cow-_ Lo.�)
{ ) I am a sole proprietor and bave no one worhdDg for me.
I aai a home owner performing all the work myself.
NOTE:plc-%c be cw-4rc t*=[t k1 ]o hcmco.4vcn.tlo auplay pczom to do -f.-••-•,= c;.:c,00 c rc;aa wcric oa[d%%,U-y of
ant mote tern t�:----ist-cls the bomoownc rraido or oa the Qoun4,zppurtcn=tbac-n[.-[oa C=�-rrry oec:d d to be
eiV'cr---D?—the---i;r"s erspI--.,;oa Ate GL4 52.-a l 5
t ( )�appliutioo by a bomaoava fcr a Gcxx_or pcnnii n_y c%idmoc the
lcgz]rt,^•^of as ctployx uodad,o Wl+k e[Compom,y;�Aac_
I-dcztaad diA a oopy of this[ tu,. w oo..y ba for-__,ied to tFw pcpartmmr of 1-ha id AcadcatY O(G-of I--Jr-th-
eov[zaCc vciGc=ioo and Uu Lilmc to serene`covcryse uodc s,QiO,23A of),(GL 152 Qa tad to the iaapIIioa of cimitW pcwltic
ooau ziu of a fine of up to SI}00.00 arwc(.ixn;,riy�ofup to occ yor cod avil pmsrtia is be fo[m o(a Stop Work Order and a
f'=o(S 100.00 a d_y aptiba tree
q7� For dcp.n[ra �1 ux onty
PCfIIIJ1 Nt1IDbC7 ---
jvL1�° t.Or° A.
S;�natun of Lic=Lscc/PcmU tcc e J
SECTION 8-CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone -
9:Re isfere' `fiFo'me liii"`rarrerYen Confracto�= `Y` y "" Not Applicable ❑
Company Name
Registration Num er - --
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFEIDAVFT(MAL.c:152,,§25C(fr))
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...... ❑
rf
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 Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature �' � —1
SECTION 5-DESCRIPTION OFPROPOSED WORK(check alanplicable
New House ❑ Addition ❑; Replacement Windows Alteration(s) ❑ Roofing
Or Doors 10 1
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[O] Other[p]
Brief Description of Proposed
Work: ✓tJZ� J� J �trrt4�r.? �1ti4 U�ll _ b ?����'!_u., ivt�(�-
Alteration of existing bedroom Yes x No Adding new bedroom Yes x No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa tf`�1ev�r�iouse�an+dOditia�.�c�:�exls�M�i�'i�=�orisi�ct:�o �i�ie�e theo(tQ�rii� :
a. Use of building:One Family__Affl 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
1, 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 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.
III C_�� � Zr:�e
Print Name
Signature of Owner/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
J.
i 4 ,�
Lot Size `
Frontage
is j j
Setbacks Front
Side L: R: L:7— R:
Rear w
Building Height
i_
Bldg. Square Footage - ----? I % r--1
Open Space Footage % p� ,
(Lot area minus bldg&paved
parking)
r
#of Parking Spaces i
Fill: ? I
(volume j&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT 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 Q DON'T 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 Q 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:
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 0 , NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
. N
Ma
Northampton eta r cr -e
' g Department r ,
212 Main Street S 'eF a ti t tii
Room 100 a
�? No'tdimpton; MA 01060 �uuSsotccafl?an �
phone 413-587-1240
Fax 413-587-1272 5 � ��
APPLICATION TO CONSTRU T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITEINFORMATION '
This section to be Completed b office
1.1 Property Address:
�� �'°Mapv Lot Urut
vtU i
Zone Overla Disfnct
a
EIm"Ik Distnct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT-
2.1 Owner of Record:
77 kM /L1 0-
Name(Print) Current Mailing Address:
Telephone t
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` Only r
..Date-
Building Permit Number. Issued:
Signature:
Building Commissionerlinspectorof Buildings Date
54 OVERLOOK DR BP-2005-0507
GIs#: COMMONWEALTH OF MASSACHUSETTS
MM:Block:29- 190 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:roofing BUILDING PERMIT
Permit# BP-2005-0507
Project# JS-2005-0667
Est.Cost:$2000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
hot Size(so A.): 234,7$.$4 Owner. FORRV,T MICHAEL S
Zoning URA Applicant: FORREST MICHAEL S
AT. 54 OVERLOOK DR
Applicant Address: Phone: Insurance:
P O BOX 37 (413) 369-8045 (�
CONWAYMA01341 ISSUED ON.10126104 0.00.00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOWS & SHINGLE
ROOF OVER L 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: OK 1a '(' - ®y
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. _
Certificate of Occu an urJ5*
FeeType: Receipt No! Date Paid: Check No: Amount:
Building 10/26/04 0:00:00 2232 $25.00
212 Main Street,Phone(;13)587-1240,Rtx-'- .3' ?;-:272