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DEPARTMENT OF BUILDDNG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '>a
.�4 Ste.♦
North,-unpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNlR 108.3.4 to
act as has/her construction supc: .-Asor. 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
�(tVJlpT
O O _
k� yti Crii� of �orff71)t}�fDn _
DEPARTMENT OP DUILDI-�\,C 1NSPPCTIOI.'S
212 Alain Street Municipal Building
+I : ?Northampton, Mass. 010GO
WOMCER'S COWIPENSATION MSURA-NCE Al=, AV1-J-
i
' (li ccvsxJperm�tics)
'Lb a principal placce of business/residencc at:
do hereby certifjr, under dic.pains and penalties of perjury hit
( I un an employer providing die followine «,orkcr's compens-nbor, coverage ',or 111y
etnPiovices worUng on tills job:
` l
�•� L��t Iyr�,•UR ��� lv LSf�3i�:��12�l-'�� tfi �'"/u�� a"7
Corer. ,) CPclir. ?Ntt_�ocr) -- (-.•pirrior, tDzL)
( ) I zm a sole proprjetor, general contractor or homeowner (c Cie Otte) amd have hired
the contractors listed below wbo have the following worker's comoentadon policies:
01;ame Of Con=dor) (Insur'ncc Coino3,i)./-prbCi !NUBl,t:) (r-X,4J ^n Date)
i
I
(N Me of Contrctor) (Insurznce ComDaativPo!ie� \uncrr) (t��irtion Date)
(Name of Coaa-acte.) (Insuranc Com
pan)-/%%-c)' Number) (Espim600 Date)
(T'ame of Contractor) (insu>an Compatry/PoLicy Numlys) kT-.% 600 Darr).
(a2a.�;dditoc3l bc•a,iln —.'ti•to c�'ucS=jarorm.Eoo p=-t .; to.11
{ ) I am a sole proprietor and have no one wor deg for me.
( } I am.a home owner performing all Lbe work myself.
NOTE:pl=.sc be zo.ut L*z o.LJo bemcavticra ubo employ pc-s.om w da¢ �–.:.ejoo c�Q-or%ao a d..clL of
not mort then t oe t_t;','in w�ch t(x botnoowo r=d.=or oa t,-gvux rS I?yUrtc=.=tbeer e ax Co ,Uy oeesd,-cd to be
e tployc s uaGe the---kcr"O=P -ai•oa Act GLt 52-=t 5
( ( )�:-ppticZDOO by n 6omeo>-oa fer a l;cx.or permit rr_y evid�x the
Ir1P1 ctanu of as cry 1oy.c uader dto WorkceL
C.omgomitaon Ad
I Uodcstx th.d x oopy or thu card�y tw for-.rdod to tl a ryopu�tmcc¢ar In&cuiJ Ac dray Offiou or Gs.u.noe for tb,
oovcab-c%,CZ Sioo and tttu Liltat to so�uc cove a�C tic so�tioa 25A of 1 t4L 152 can led to the i=Pcuifioo of aimi-J peaaliic
co=iaix ora rux orup to s 1 Soo.00 u]dlor t orup to one year tad cN l pm+$io io the form o(a Stop Work Order nod
rim of:;100.00 t d_y tpa=tree
/( For dp-us'=�t u,c drily .
1,4M P., Lot R
S;p�1LUre of Liet�scelP�crTruuee ate --
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder: 1410 Z RA 10
1 C7 License Number
Address , Expiration Date
Signature Telephone d
9.: te isteed,l�amem �avemeiat.Contra toil'=X2. � °� Not Applicable .❑
Company Name , Registration Nu
Address
11,�� Expiration Date
/ry 2 r 70-L-5 TelephoJ4/3 .SSd—y p
SECTION 1'0-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GtL.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 building1permit.
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 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
SECTION 5--DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Wj Idows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[V Other[❑]
Brief Description of Proposed
) �/ /�
Work: —�As ��A j( �'l N
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa Ifi New° o61 se�ai 6"F cllit>ION, - 61 xls#ir►a hn rncl mp a Cie o i0 lna:
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
L 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-:OWNERAUTHORIZATIONTO BE'COMPLETED WHEN
OWNERS AGENT OR'CONTRAGTOR-APPLIES'FOR BU[�DING:PERMIT
TO as Owner of the subject
property
hereby authorize J�,lO
tn myob If, in all m e e to work authorized b this building permit application.
Signature er Date
I, "�`'�� — '� / ,as_4 weer/Authorized
Agent hereby declare that the statements and inforrfiation 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-liftw6r/Agent Date
**
,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This colurrin to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bIdg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special ncling ever been issued for/on the site?
NO 0 DON7KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry nf Deeds?
'
NO 0 DONT KNOW 0 YES
IF YES: enter Book Pa and/or Document#'
'
~�
� � �~�
B. Does the site contain obrook, body of water orwetlands? NO �~�~� VU x��DON7 �NO YES «�/
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained �� �� ���'
v~� \_� ' �
C. Do any signs exist on the pnnparty »�� �`�� YES \~� NO �_�
|F 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:
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre oris it part ofo common plan
that will disturb over 1acre? YEGf��) NO ����
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
t s
.�,�� • � �`-`�"De sew nl��- �
City of Northampton
Building Department
212 Main Street
Room 100 4
Northampton, MA 01060 e k �
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION:I -SITE INFORMATION
1.1 Property Address: � Tbtssectton to be,completed by office
x
7` j ( �QISe OVEIfa �tStrlCt'
Vo
,Elio Sf Cllsfrrck CB Distract
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nam (Print)i Current M�i(i n Address:� j et
Telephone
Signature
2.2 Authorized Agent:
Z�coy J kAl.J ��J ��1 �. �'1 N�i�. ('1 �11�'J 7'0� �'✓�%G`'
Name(Print) Current Mailing Address:
Signature Telephone
-SECT.ION3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by ermit applicant
1. Building s jpr),Building Permit Fee
/ ?00
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) J a. 000 -4, Check Number lot U,
This'Section For Official Use Only
Building Permit.Number. Issued:
Signature:
Building Commissionerlinspector of Buildings Date
BP-2006-1394
GIS#: COMMONWEALTH OF MASSACHUSETTS
�' " f,, CITY OF NORTHAMPTON
vr-
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2006-1394
Project# JS-2006-2064
Est. Cost: $12800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin B & R Siding 100465
Lot Size(sg. ft.): 15333.12 Owner: VITO MICHAEL J
Zoning:URA Applicant: B & R Siding
AT. 28 BEATTIE DR
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:612212006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL SIDING & REPLACEMENT WINDOWS
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 Si nature:
FeeType• Date Paid: Amount:
Building 6/22/2006 0:00:00 $25.0020416
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo