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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 780CNM 108.3.4 to
act as his/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 twofami y ---
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 bulb-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 backfilI),
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 ?
understand the above.
(Home owner/resi is signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit "
- - issued-to me.
Daze /c0
Address of work /�?
location
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I a;sack a6r1la'
u. o DEPARTMEI-TT OP BUILDr�,,C INSPPC7jl0l:5
212 Alain Strcet Municipal Building
Northampton, Hass_ 010GO
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WoRral R'S C001:1)ENSATION MSURA-NCF- : FFD)r�,.vrr
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(li�nsxJpc;mi ttcc)
%%IlLh a principal place of business/residence at; - -
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{ do hereby certify, under thc.pains and penalties of pcqury, :hoc
! ( ) I an an employer providing the foil o%ving;v,,orkc>✓s coinocasa:30n coverage for Illy
emplovecs 1-or13ing on tills job:
(Lasu1-�ac (Poiic:Nu--zibcr) -- (� :piratior.Dom)
j y
( ) I acre a sole proortctor, general contractor or homeowner (c Cie one) an- d have hired
the Conti actors listA,i below wbo love the foilowiog worker's compen_sabon policies:
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(Namc 61 Co_'-'^CiD") (Inslr ric-c Cotnpanl ,iPobcj
(Namc of Contaaaor) (lris'sfanC; amoanVIT'OUn, Numb-zr) (Expim ion Due)
(Namt'_ of CO=C-[d-.) (Las r-anc-- CompareyfPoucy (Expim600 Dam)
(Namc of Contractor) (Lamranc-- CompanyfPolicy Numbs) (Et-pinion Dais),
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(aC.].:3 mod..:-ocsl LScG,iro��---•.ti.u cducL iarorr oc p ruU to.11
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O I-am-a Sole proprietor and have no one world-ng for me.
I amt.-a home owner performing all the work myself-
NOTE:p!'-.-be cwzrc q- +^3c sacra a.bo ca:Ploy p--;.a=to cia -• • c mpair-orz oa a d-c -z:of
woe morn then t41ee this is ieh the 6omoownc r=d=a ee the pbua6 zppsrLca oot C==Uy,Decd--Cd Lo be
-MV'c --z un?—the .T...- oci Aa(GLI152.=I(5)�-.pPU=.iaa by.bomeagaa fc a G�c o:pcmit 1 a idax else
Ic-gs]ri-^••of en esaioyx uoder d-Wocfola Compom.sio Act-
I ..""+ad dsa s ooQy orth6 cat,=1 m.y be fo�.orded to ebo p.epartmeoK orin�x.�ric!Accj&=r.'office or lraur�ooe for Lb.
oovea�e vc'if esioa sad th:I L-iltac to ea.-ur-.'eovt�y�.���3aCCion 25 A ar htQL 1 S2 oa k_d to the i�sPcaitioa of e-imias!peaaliia
of a fwc or up to S 13oo_oo a,wo,ia�, oru to Doc
P Y=e.d civil pCwCia in tSc form of.Slop Work Ord=end a
fi=of S I Do.DO a dtp cgyirt4 /
., For d�arsNUM - Doty
Pcrmit 1�ittmtxs
Lot R
Sl aauu1C f Li rmiu= e
SECTION 8-CONSTRUCTION SERVICES {
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
Company Name Registration—Num er —--
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION:INSURANCEAFFIDAVIT`(K0.1 c.152,:§25C(S)).
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 1083.5.1.
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.
T e undersigned"homeowner"certifies and assumes resp abi ' for compliance with the State Building Code,City of
orthampton Ordinances,State and L 7�oning Laws d S to of Massachusetts General Laws Annotated
Homeowner Signature_,,: _
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SECTION 5-DESCRIPTION'OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑:: Replacement Windows Alteration(s) ❑ Roofing
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[a
X f Description of Proposed rk: I �� "/\
Alteration of existing bedroom Yes_ No Adding new bedroom Yes _ly— IN
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa i�� OU' se n ddi#iai fo exis. p O sin r;om Qit+ a ieg o ow, rr :
a. Use of building:One Family 0 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 AUTHORIZATI,ON.-TOBECOMPL"`ETED'WHEN
OWNERS AGENT'OPU CONTRAC TOR,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.
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Signature of Owner Date
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 pain4 and penal'es ol perjury.
eC4'
Print Name
- 31--o
Signature of Owner/A enK Date
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Section 4. ZONING All Informatioh 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
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Lot Size
Frontage
Setbacks Front --- V
Side L:' R.' L: R
Rear
Building Height
Bldg.Square Footage i %
Open Space Footage %
(Lot area minus bldg&paved — I
=king)
#of Parking Spaces
Fill: i
(volume,&Location
A. Has a S ecial Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW 0 YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW 0 YES
IF YES: enter Book Page' i and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 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: s
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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City of Northampton wt
Building Department � 1'T
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212 Main Street
Room 100
Northampton; MA 01060 r
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
77]SECTION 1 -SITE_INFORMATION
d b y ffi
1 Property Address: Th1s sectior�to�e carr�ptetecce
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////'' j�'�J f'asf♦�G C�`�_'E�
PC nit't.'
��Y'�!C't. i``-"t�5 Zone'' , ^ s•Ouert�ybis�ct
SECTION 2-PROPERTY'OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Pnnt) Current Mailing Address:
Signature Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-'ESTIMATED�CONSTRUCTION COSTS
Ite Estimated Cost(Dollars)to be Official Use Only
complete bv permit applicant
1. Building (e)Building Permit Fee
2. Electrical
Ati}-Estimated;Total Cost-of
Construction from 6
3. Plumbing / y) Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check-Number
51 W�6
This`Section For Official'Use Only
Building.Permit Number. Date
::Issued:.
Signature: r
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Building Commissioner/Inspector of Buildings Date
143 DEERFIELD DP�. BP-2006-0485
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 193 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
CategoryL. BUILDING PERMIT
Permit# BP-2006-0485
Project# JS-2006-0707
Est.Cost: $1800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 15028.20 Owner: LEBRON FELIX
Zoning URA ppUcant: LEBRON FELIX
AT. 143 DEERFIELD DR
Applicant Address: Phone: Insurance:
143 DEERFIELD DR
NORTHAM PTONMA01 060 ISSUED ON:111212005 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 11/2/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo