29-237 (4) O�gtiAMP�O
Crzfly of Xort4anrptan L
� � �i taesa�l��isetts -
DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060 5
,r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supc,,ii 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 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, 1\/ understand the above.
( ome owner/residents signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 2 _-S
Address of work
location e J
b 61111 of
13 l R til 115 C 115
DEPARTMENT OF BUILDING INSPECTIONS
212 Maui Street ' gunicipal Buildill
Northampton, Mass. 01060
WORICER'S COMTENSA'MN INSURANCE A. + `DDAVI-T
1 -- - —-- - -------- —--------- - --- -- ---
,vith a principal placc of bush esJres;denc
strccticir,istt::�n;)
( ' : .` S al-'a },
C10 11CI'C)} Cer"�LI}-, L] l ' S he p%:ilS 1)C;ilaltiCS Oi pCf�lli � '..Ili?:_
O I am an employer providing t}1e follo',vint, v orr_crs coml)cnsnon covere c for MY
employees worldrlg on t}tis job:
(Iassran= Company) c-c.Number) ---- (F>Tpir,:tion Date)
j I am a sole propi-Ictor, zentral cc-'M-Lc cr ;circle Oct) and '--'- -e hired
the contractors lister. be o v �vho 1: the fo__•.. :�_: `:--o;r S Comp neon rpe
(-Name of Conn tutor) Date)
(I Iarrie of date)
r C, --3--.,.,., - r�:do� at,--
(i�'ame of Contractor) (Ins�r-ulce ._<„y :_�,IPol;c; t�uritf�r} `-1. Dal,--)
- (Name of Contractor) - (Ins�ranc COLLi �I}'/2 O11C'J ItiStlIIlrr r) (-�,`:u: ii70:)Date)
nil�.�..:_._...•.l
( 1 �1I17..i: OlC p(Oi)I7 ��li 2.1'1 h v' 110 Oil
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ae be na:e t!u:.,1_iie tx<nco,,:ra,, :o c: pl ;,r_:._ a;:> inch arse n m c :c;a r«
n -
not 11K'cc th:a tfiroo unirs in t,f:c'1 —a u a;
c�'.ployca u_ti:cr tlr tvc;i:ci s cam^~--•._:icn 1•.c:(GL152.::;(Sl ,a,:,lic::i^;:::y a ho:aro„�cs`br n Lccu a p-rs:: ....'..roc;t.c
]cgal ctntuc of an cmvloyx uod ti_o LVorl<cr&Car;o:i!ion -ct
I undcztand thi_a copy of l}u ct_[c._2t r:.y bo forti,', 'c 3 to L»1YtiartzYn:of Ir>dzisvri cl P,n�dc,t.i Ci:cw of L�.vv't=n for L!x
covcr&gc vaiflczttioa and that G.ilurc to in uc cover ur3 r cC,ic^25A of MGr,152 can 1c ci to tlx ilnpositioz f cry it 1 pc al:a
comiuting of a fur_of up to S 1-SC'O.0-o of t:p to cr.:}- r:-A evil'p=u1 iu in uc fc nn cf.,S!r,'`;'nY.nti=-rA'
fir--of S 1 QO.W e day iszina m:.
ioc ciq%uuxratsl u.c u,ly {
I11IltTt1 �
1 i
5i nature of i.iccn. JPcrrnirtr. r .-,
IOU 8.=CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicablei
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Reg s ere . -M- m'Qrowement C^^ � ^• Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SEGTIOH O0 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...... ❑
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 ther-2
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"homeoNvner"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 fur 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" rtifies and assu es responsibility for compliance with the State Building Code,City of
Northampton Ordinances, at nd Local Zoni Laws nd State of Massachusetts General Laws Annotated.
Homeowner Signatur �•
SECTIONS,DESCRIPTIONIOF"PROPOSEQ WORK(check afll ap Ica p ble)
.: _.,.r ,..:`w`�'k"�'�,�", ..�w�v'°l.lx'"$..+.'�. :.�ka.£.=r'"il."°�. ....::.. ,a...,._ ,... °.. - r �`�.... m.�i:.a ,.•1�', �'-r
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofings
Or Doors ❑ /
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ Other [
Brief Description of Proposed Work: no C'Onc-)r) S�z�L`,� cx.l,� ,�/C(✓�,� ��-��
OVA I cI _-, -_
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
6af: VeWot�,sa:ntl:�or�diiition��o exis`tmg.°l aousrngcom-p:le�e�the-followin�
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. bimensions
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? 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 DOWNER AUTHORIZATION TO BE COMPLETED :WHEN
OWNEkS AGENTO CONTRACTOR APPLf,ES. fOR BUILDING PERMIT
as Owner of the subject property
hereby authorize to ac;. on
my behalf, in all matters relative to work authorized by this building permit application.
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 pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
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 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO /� DONT 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 n �
Building Department - �
212 Main Street
Room 1001
Northampton, MA 01060
� .
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, E VjE A ONE OR TWO FAMILY DWELLING
1
J 4pp4 �� 1
SECTION 1-SITE INFORMATION `
,� ' � � to.be completed by office
1.1 Property Address: 4p'
Q/ / �
( �.-"' per titt�fi
� � 1
-- �Zane � O�rerla�l3�stnct'
Hm St''V Distrrct � '_ `CSJDrs6rict
SECTION 2-PROPERTY-OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Maili�ngg Address:
f A- Telephone
Sign re
2.2 Authorize ent:
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 9 (a) Building Permit Fee
2. Electrical l (b),Estimated Total Cost of
Construction from 6
3. Plumbing Buiiding Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total = (1 + 2+ 3 + Check Number S This Section For Official Use'Onl
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
w #,
21 ALAMO CT BP-2004-1318
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-237 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-1318
Project# JS-2004-1979
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa. ft.): 10018.80 Owner: GEIS DANA J&KIMBERLY A PALME
Zoning.URA Applicant: GEIS DANA J & KIMBERLY A PALME
AT: 21 ALAMO CT
Applicant Address: Phone: Insurance:
21 ALAMO CT O 586-7100 O
FLORENCEMA01062 ISSUED ON.6123104 0:00:00
TO PERFORM THE FOLLOWING WORK.SHINGLE ROOF OVER 1 LAYER & INSTALL
WOODSTOVE
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 Sienature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 6/23/04 0:00:00 516 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo