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DEPARTMENT OF BUILDING 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 iJs/her construction sup i'ha stale defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or hvo 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
5
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
c
Address of work
location � V of Q_u t�o J
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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
L9 1Reg stered`HomeIrriprovement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(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...... ❑
1 om?e®.caner EXemp,on
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 thejob 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 State of Massachusetts General Laws Annotated.
Homeowner Signature Lz
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SECTION 5 DESCRIPTION'�OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s)X 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
6 lj f=NdW.3house:atidibe-,atldition°to"existing-h6using co'mplete:ahe following:
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. i _______ 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?`i 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 ac, or,
my behalf, in all matters relative to work authorized by this �,uilding permit application.
Signature of Owner Date
1, c cL vi _ a Owne /.Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accfe, to the best of my
knowledge and belief,
Signed under the pains and penalties of perjury.
Print Names
. 63
Signature of Owner/Agent DA
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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
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 DON'T KNOW YES
IF YES: enter Book Page _ and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 S`MGM
'Per==.
Building Department C�rbCutlDo e e
212 Main Street Sewer/Sep is tab ,
Room 100 Wa pr el Ava ab
Northampton, MA 01060 TNIG3 of Str c ural a,s
,� , .0w�
phone 413-587-1240 Fax 413-587-1272 Plot/Slte'Plans=
' Other Spec�tfy � , r � � ;' ,���`g
APPLICATION TO CONSTRUCT, ALTER, REPAIR, REf3.0�AT1±-0R'DEMOLISH A ONE OR TWO FAMILY DWELLING
MAY 2 7 2003
SECTION 1 - SITE INFORMATION
This section to be,-completed by office
1.1 Property Address: t
Map Lot ` 0 ni
Zone 0verlay'District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nam (Print) Current Math',g Address:
Telephone
Signature -- ---
2.2 Authorized Aeent:
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 -q (a) Building Permit Fee
2. Electrical 4 1 (b) Estimated Total Cost of
_ 5O) Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = () + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building'Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
•s�
File#BP-2003-1069
APPLICANT/CONTACT PERSON QUINN'RICHARD F&DIANE L
ADDRESS/PHONE 114 BRIERWOOD DR
PROPERTY LOCATION 114 BRIERWOOD DR
MAP 29 PARCEL 166 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid "-
Typeof Construction: UPDATE BATHROOM W/TILE&NEW FIXTURES
New Construction
Non Structural interior renovations
Addition to Existin
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INY99MATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW _ Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Colrnission
r_
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
114 BRIERWOOD DR BP-2003-1069
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29- 166 CITY OF NORTHAMPTON
Lot: -001
Perrnit: Building
Category: BUILDING PERMIT
Permit# BP-2003-1069
.Project# JS-2003-1698
"--Est. Cost: $6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: 5B Contractor: License:
Use Group: R4 Homeowner as Contractor
Lot Size(sq.ft.): 11151.36 Owner: QUINN RICHARD F&DIANE L
Zoning.URA Applicant: QUINN RICHARD F & DIANE L
AT: 114 BRIERWOOD DR
Applicant Address: Phone: Insurance:
114 BPuER WOOD DR
FLORENCEMA01062 ISSUED ON.613103 0:00:00
TO PERFORM THE FOLLOWING WORK:UPDATE BATHROOM W/TILE & NEW FIXTURES
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:1//Y Rough: 61� House# Foundation:
Driveway Final:
Final:-21 Final
3 V' Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY TH;CIT OF NORTHAMPTON UPON VtOL�-TIO F
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anc
Sit
nature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 6/3/03 0:00:00 2911 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner- Anthony Patillo