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DEPARTMENT OF BUILDIJ\1G 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 i:is/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 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
I, 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
Address of work
location
(f it) of �'Tortilailiplott
�Zasa rhncrtla'
o DEPART MEKT OP BUILDP,�C INSPECT101.'S
212 Main Strect Nfunicipal Building
Northampton, Mass. 010GO
1
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W0JUC1CIZ'S COMTENSA-MN MSURA�CF All=, VIT
I- iccu xlpermitic�)
\I.rith a pru_tcipal place of bLusIGtSS/FcSidCnCC at:
0 YU MAI (phone')
do hereby certify, under the pairLS --ad pen2lties of per3ury:; .hat
(01, am an employer providing the followine ,,.'orkcr's coinoensado 1 cove age for my
etnplovees wor 30g on liiis job.
/xl/-6f -10 '7
n�COMMny) (PcLic:N-Umb^_r) (E:-pintion Dpi-)
( } I am a sole proprietor, general contractor or homeowner (ci cie oee) aad hzve hired
the conuactors listed below T--,bo hzve the follo"vine workers coo7enS2aon policies:
0"larDc of Conrncw-) (In_ur-an cC Coinw i)•lhobc) NLLmh--r)
(Name of Conmctor) Oinst-anc_ Compaaw?oUc-r Nun6cr) (Ex-D7.6on Date)
(Name of Comaao,) Cim urancc ComT=3-1Pol-q- Nwnbu) (Expirtieo Dam)
I
(Name of Contmaor) (Losuranc—c ComcanylPolicy Number) (Etpirdoa Daic) .
(naA,=b-36,60csl rhca.if to c ?uc5c;nronn =joo Pcr�w.11 coda-_c..oz)
{ ) I am a sole proprietor and have no one wor16ng for me.
( ) I atn,a home owner performing all Lbe work myself.
NOTE:pl=sc be tw-Art tbct vt.)e beaacovv rs uto cloy pcsotn w do 0=_,:cj m r rte,air-ark on.d --Z of
arx moCC th a :sr_—,J is u3ieb the bocnoown,:r 1-=d-a or oa the p-ovary z7puriev_r1 tbcceo e,we C=>, Uy owed.-�d to be
enploycs unGC th -=k=r`s o==pc=stim A=(GLI :p G=6on by n bomcoava fcr c lien-a pama r>_y`rd tl,c
Icy!nazis of na err,loyal uoder ttso workda Compom.t ACL
I uadczia pd the x copy of this mt�o y bo forwu%Iod to the Doputa cf lndurricl OM of kauz000 for lha
oovcr. vai c=xioo O:id thrl L-ilLm to cavrc'eovern;�under soerion 23A of MCL 151 m fed to the i,,,,,soa orcr=10-,pca+w,=
co=;Zim of a rux or up to S S00.00 xnNcr =priso®csl or up to ooc year rnd cvi]Pm,ji in 6,roan of.Stop Work Ord=nod a
rtrp oC S 100.00 a day•p•inst me
For 4cprta'='1 u,c only
perrait NLLmbcr
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Sign �
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: �( Not Applicable ❑
Name of License Holder: C-- +�'' f L
License Number
Address Expiration Date
Sign g!ure V Telephone
9--=A&1ISf@red'Honit:*tri1016 eme6f ntra&oX' '
`� ��- � �, x Not Applicable .❑
T3 sL ) ) 00
Company Name Registration Number
Address Expiration Date
Telephone 1&7
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G'.L.c.152,§25C(6))
Workers Compensation Insurance affidavi 'must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildiVt 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 buildine 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
f .
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Rool2ng ❑
Or Doors 1:3
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding Other[ol
Brief Description of Proposed �� $ �-� / V/
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
• Rx't'4,.. '3w}Y°4 Y+'2lik .. "=' .Z+ .t'n:. 'a, x' sy 11 1,--' mg 6f -'
sa_��New�lioase and orac�tl�orr�o%exI'stincl housma;�corr>plete 1heo1[owrrig:
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-:OWNER AUTHORIZATION-TO BE COMPLETED VHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR.BUILDING PERMIT
A)C ('� � �G IJ �S as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this buirding permit application.
Signature of Owner Date
zff ✓y 1j i'5 ",V4 as Aww/Authorized
Agent hereby declare that the statements and information on the for oing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
-rL��,� 1� ✓z-�v
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Print Name
Signature of GQXi`+*>'Agent 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
Rear
Building Height
Bldg. Square Footage % F-
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location) V
A. Has a Special Perm it/Vuhunca/Findi ng ever been issued for/on the site?
�� ��
NO �~��� DON7KNOVV «_� YES «��
IF YES, dote issued:!
IF YES: Was the permit recorded at the Registry ofDeeds? '
��
NO �� DON7KNOVV 0 YES
IF YES: enter Book Page and/or Duoument#� !
'
B. Does the site contain a brook, body uf water orwetlands? NO 0 DDN7KNOV 0 YES 0
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �~� Obi v�� Date
�~� �~� ' .
C. Do any signs exist on the propert �� ��y? YES v_� N0 v��
IF YES, describe size, type and location:
--------------
D. Are there any proposed changes toor additions ofsigns intended for the property? yB 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb .grading, excavation,nr filling)over 1 acre nris it part nfo common plan
thowi||diotu,bovo,1onre? YES K ) NO ��� �
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
a �e �vuse nt ,
F
of Northam tons
��Iing Department = � �
l L, 2 Main Street t k x
Room 100 tit v
Noohampton, MA 01060
_pfib 4,fa-5-7=1240 Fax 413-587-1272
`�
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION'
1.1 Property Address: This section to be completed by office
�=
j
fe./ W O� �. - Map :Lot Unit,!
Zone Overlay D�stnct s
Elmi St district t C13Distrrct
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: p
Name;(Print) Curr I ailin Address: Q j
L Telephone r s t o
Signature �'>
2.2 Authorized Agent:
Name(Print) CurrJnt Mailin Addre
Signature Telephone Ei
SECTION 3-'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
m/l�eted by permit 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
me
6. Total=(1 +2+3+4+5) /d 6 Check Number Q
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
s.
BP-2006-1178
G1S#: COMMONWEALTH OF MASSACHUSETTS
a1 � "�` CITY OF NORTHAMPTON
a
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2006-1178
Project# JS-2006-1736
Est.Cost: $25.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq. ft.): 10367.28 Owner: JONES PETER A&ELEANOR B
Zoning.URA Applicant: B & R Siding
AT. 105 BRIERWOOD DR
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:51312006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING
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 5/3/2006 0:00:00 $25.0020341
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo