29-277 (2) �Tt1AMp�,
city of Naztl amptan z =
$ � �assachusetfs
DEPARTMENT OF BUILDINIG INSPECTIONS /
INSPECTOR '212 Main Street • Municipal Building
Northamptcm,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction sup(:: ,, :,or. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or twofaym --
dwelling, attached or detached structures accessory to such use and/or faun 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 f,,egulations. 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
in de
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.
i
Date V -174 -7
Address of work /`
location 3 . j /^O C9/L
o/Q67 -
0
B f �7asa itch nsrlla'
o DEPNtTMEIJ7 OF DUILDD\10 lNSPECTIONIS -
212 Main Strcet Tfuniupal Building
Northampton, Mass. 01060
WOMCER'S C01\10 ✓NSATTON MSURA-NCF AFFD)AVI-1-
I �
(Ii cct>sxJpermj tfcc) - - —-
\I-rith a pr"Mcipal place of businessfresidencc at: — -
(sit/ci t-J/stall/ap)
do hereby certify, under Lhc puns and penalties of penury, ha i
1
( ) I am an employer providing die following"I m -:ion coverage for im
eluplovecs
wortang on dies job:
i
(insure Conr,:�•) (F=lit: ►:umrr_r) ----. (r:-pirrior.Das.) -
j -
j -
O I am a sole proplretor, general contractor or homeowner (cc;z one) and live hired
the coouactors listed below wbo have the `otio%14 Q wormers c000ep_s2aon policies:
i
('Name of Con=ciCr) (Insurance Cornoan)':Poiicy N\runl_C:) (Expilau0n gate)
I
I "
(Name of Coalsaaor) (Las-tu-anc:. ComoanviPo6m Ntuacrr) (-EiDir,lion Date)
I - -
j (Name of Coa=CIO.-) (Insw-anc; Compan)-/PoUc)- Number) (Expirtion Dalc)
i
i
02!amc of Contractor) (Losuran(-- Comcany/PoUcy Numbcr) (Expiration Datc) .
(nII�.CfI zddit oc�.!c'xG,if accazn-to a�cu�taforma.•ioa pcta.inia6 w.0
I -
!
{ ) I am a sole proprietor and have no one woridng for me-
I am,a home owner performing all the work myself.
NOTE:plc=be ecru=tt`••ktJc bomoo�M=-bo cmplay p--=. Lo do n= =,,zc:ao c rc;a r went M.d-vim—Z of
aot eacce than `tl o.=?"is«-,;ch the boca .wc nsd�cc oa the Vwou �zppurtco lb=w�- oc<g�rlly o-rsd--td io be
cmploycs und—the—k=: -c c=p=•,.ca Aa(GUI 5)3 I(5)},applica.600 by a bomooava fc n Gczr—_or permit rt_y ec-idmoc LL'c
lcg�.I rtayc of as cgloyoc oadar dro W«icolc Co¢xgamalioa.AIX .
I
- [undasz.aad a Dopy of thi.ca.t®-=o y be for—ard.ed to tho p.cpucmca¢of r ir�—fot th.
eovcrxsc vcrirt=lioa mad th:l L-iliac to soosrc bovcntct undo u>=r ce 23 A of 1.(QL 1 S2 me led to the ia�OSitioa of aimins!pco�lIica
ooau: iztg of a riot orup to s I}oo.00 mad c, of up to ooc y=tad civil pm.lue io tx focal of a Stop Work Ord--Lad a
rim of S l 00.afw&d_y.,iu me
F«dcp.rtrzu'1 u,c Drily —•----
a� pertmt Ntuni>c
,, r
J`raaUim of Li crmitt
cQtscrJP cc e .
SECTION 8-CONSTRUCTION'SERVICES 71
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9 Rea>seretoin ll'iia vineri �o�ttt�icto' F Not Applicable ❑
Company Name
Registration Rum er ----—"
Address Expiration Date
Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCE AFFI6AVIT'(M.G1.c 452,,.§25CF6)):
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 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
orthampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
r
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all aoplicabtel
New House ❑ Addition [].. Replacement Windows Alteration(s) Roofing EJ
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[O] Other[0]
Description of Proposed K .
n""` Gv 1 p " ./
Work: �_ !j (it!''�"�"�
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa_[�Nevtr+:�rouse�a�`i�cat�ad'drfi�' ��sexist��c>�.f>€OUSInc��_Car�a�e��;�he�fd�Iourrlr�g:
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 Ta-.OWNER AUTHORIZATION TO,_BE COMPLETED WHEN
OWNERS AGENT OR CONTRAGTORAPPLIES'FOR`BUICD(NG 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.
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 Na�����/,
Sig an ture of Owner/Agent `,I(�(J/{� Date
' *
`
Section 4. ZONING All Informatj6h 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
Re
Building Height
Bldg.Square Footage % i
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
,
(volume,&Location)
A. Has a Special Perm it/Vahanoe/Findi ever been issued for/on the site?
'
NO 0 DON'T KNOW 0 YES 0 �
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON7KN0N 0 Y[3
IF YES: enter Book | Page and/or Document#:
�� ��
B. Does the site contain u brook, body of water orwetlands? NO �~��� DON'T KNOW v�� YES �~�
IF YES, has permit been or need tu ba obtained from the Conservation Commission?
'
Needs tobmobtaivad v�� D�tmimmd �-� 0ate�ssuad'
v�� �~� ' '
C. Do any signs exist un the property �� ��� YES x_� NO �~�
IF YES, describe size, type and location:
D. Are there any proposed changes tooraddiuonsofsigns intended for YES NO =
� -
IF YES, describe size, type and location:
E. Will the construction activity disturb grading,excavation,m filling)over acre oris it part ofo common plan
that will disturb over 1acre? YES K ] NO K )
~�' � `~�
|F YES,then a Northampton Storm Water Management Permit from the DPW is required.
-1Vortoampton
� u g Department t
Main Street ser t
dm 100 rye 1 st.. h
2Qb�rth( Itc�in; MA 01060 S�s. Struct t`ra fan s
phL 413-58f-12 Fax 413-587-1272 Pto Stt+ Can
APPL{IX#Pld1�1t0�01VS fkL'hER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Thts sectilon�to be comPCete'd�byoff-ice
61 Property Address*
�,�Q /"c.�i✓Z 'L`C/ " ��� Zone O�r,'04 rDWcf
EfittSt.Distrrct_. __.. _ CB Dist�Ct. .
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Ree rd:
Name(Print) Current Mailing Address:
• ( /� -+C Telephone
7
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
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
O �
6. Total=(1 +2+3+4+5) Check Number
This Section ForAfficial Use Only
Date;
Building Permit Number. Issued:
Signature:
Building;Commissionedinspector of Buildings- Date
• "M�w
335 BROOKSIDE CIR BP-2006-0005
QNV: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-277 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0005
Project# IS-2006-0008
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group Homeowner as Contractor
Lot Size(sq.ft.): 23086.80 Owner: LAPLANTE ROYAL W&KAREN M
Zoning:URA Applicant: LAPLANTE ROYAL W & KAREN M
AT. 335 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
335 BROOKSIDE CIR
FLORENCEMA01062 ISSUED ON:715105 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 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 Occupangy Signature:
FeeType• Date Paid: Amount:
Building 7/5/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo