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mss. DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
1V S.,y
Northampton,MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 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 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, 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
IA understand the above.
( ome 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--] I
O I Olo
! r
��1VJ•fP�.
(rii� t7f ��nrfll�nl}�fnit
y �a3aarllrttcffe' -
DEPAR7 METJ7 OP DUILDr1\C INSPECT IONS
212 Alain Street Municipal Build'
Northampton, Mass. 01060
t ;
«'OMCEIZ'S CON11PENSATTON ONSUSNCE Al=I AVIT
1'
(IiccnsxJperm�t`cx)
x Vith a pi�icipal place of business/residence at:
(scr�tici iylstalcla p)
C
do hereby certify, under the pau7s and penalties of penury.; That
( ) I am an employer providing the followine worl:ct's colnocns:aior, cove age 1'or Illy
emplovees ivoriang on this job:
_ i
(Insur-� Conr,�nv) (Polio:Nurnbcr) -- Cr :pirauorl Dzir}
O I am a sole propr,etor, general coa=aor or homeowner (c cle one) and have hired
the contractors listed below r-rbo have the following worker's caioensadon policies:
i
(Llnimc Oi Co"^cior) (In--urancc Coln0a I)'PIrbc Datc)
j
(N:mc of Conmaor) (Irisuranec. Comoan)vpobc Nurnc^r) (-EiDIrsaon Date)
i
(Name of Coun-2CIOT) Qnsurancz Compao)•JPoUq- N mb�.r) (Expirdon Date)
(Name of Conc motor) (IlisuraIIc_- CompaQ [Policy Numb:r) (Expinuon Darr.).
(atsxb Addi':Ocal nc( to to all oo�r-ten�)
{ ) I am a sole proprietor and have no one work-ing for me.
.( I am..a home owcer performing all the work myself.
NOTE:plcsc be aw-ut tbneI;i1c bcc: o=+vcn ubo employ peso=w(Si -• -s -a oo c rz;av work on L dXU'_'y Of
not race,then ti _,era is u'aicb the bomrwwve raid=«oa the pv,,6,,-rpxttenr1 tl�ccea Lm DO(Cc=-Xy ocrsd.-rcd w be
eixployes--/--the Act(GL152ss l(5))�=pptiaaon try a hommave fes c lies.or pamit 21 a-id—Ebc
i
Ic7gJ M--=oC as==Ployx uoder din W ockor'a Coaspaoylioa Art
I uada-�aad sha a non or tbia mt®oy may ba roc-xn,�ded to d-D.9-1maod of la�+z id Ac�adcatY C ff oC lra+raooe for t,6o
oovc�vCririC=ioo a.'fd ttt-u L-_iliac to =dc r=,=joa 25A or),IGL 152 c.led to the iz>pos> -oleimi=l Pc U-
000s.isJag of rice or up to SI�oo.00 and/or ia>;_6Oataey orup to ooc y3r Lod ovit paulcia is t�roan ora Slop Wort Ord,Lod a
Gm or S100.00.&y cvu=Mr-
Fr�or dcyartm=-��u,c not y
/1 of I�crmi 1 N trII b=
fi
Lot n .
_iTLe
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
0ARi6di =x- Not Applicable .❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G L.c.152,§25G(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...... ❑
llffa
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-vear 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 buildine 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 an d Loc Zonin 7 Laws and State of Massachusetts General Laws Annotated.
e
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable
New House ❑ Addition ❑ Replacement Vvindows Alteration(s) ❑ Roofing ❑
Or Doors I�
Accessory Bldg. Demolition ❑ New Signs [O] Decks [p Siding 19X Other[C]
Brief Descrip'on of roposed a,
Work:
Alteration of existing bedroom Yes No Adding new bedroom es .�—No
Attached Narrative Renovating unfinished basement Yes xl� No
Plans Attached Roll -Sheet
sa.ifi eW house. nc orax 1 oni#o:axis#Incr,fioraslna Per-tiff o tainrtng:
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 7a--OWNERAUTHORIZATION,-TO BE GOMPLETED ;WHEN
OWNERS�AGENTOR CONTRACTO,R�APPLIES FOR-BUILDING PERMIT
I as Owner of the subject
v
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, a`� ��( , 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 th�pains and penalties of perjury.
Prin Name
Sig a ure of Owner/Agent Cate
^
^ ^
. �
Section 4. ZONING All Information 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
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a| Pormit/Vehonce/Find ever been�yuedh�/onthe s�e?
Xh ��
��
NO �~� DON7K�OVV ��� YES ��
IF YES, date issued:!
IF YES: Was the permit of Deeds? '
NO 0 DON7KNOVV 0 YES
IF YES: enter Book Pagei and/or Dunument#'
B. Does the site contain a brook, body of water orwetlands? NO DONTQNOV 0 YES 0
IF YES, has permit been or need to ba obtained from the Conservation Commission?
Needs tobeobtoined /~� Obtained �-« Date
�
*�� '
C. Du any signs exist on the property? YES 0 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
|F YES, describe size, type and location:
E Will the construction activity disturb or filling)over 1 acre mis it part ofocommon plan
thow0distu,bnvor1ocre? YES NO §R
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton 3 ,�
Building Department
212 Main Street ,
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 _
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
ectior�to bb completed by office
1.1 Property Address: ;+
_vTI.!`.i,J �("I R_
1 �. Ql�i�.- :`Zone Oyerfay Drstcrct
�EI"in.St:Cl�str�ct '' � CB.Distr�ct m
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current MaMrb Address:
Telephone
Signature
2.2 Authorized Agent:
1�1A
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 �O (a)Building Permit Fee
2. Electrical (b)Estimated'Total Gost of
Construction from. 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number zlm
This Section For Official Use_Only
Building Permit Number te
r. "
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2007-0062
APPLICANT/CONTACT PERSON PRATT LAURA A
ADDRESS/PHONE 71 LONGVIEW DR FLORENCE (413)585-9588 Q
PROPERTY LOCATION 71 LONGVIEW DR
MAP 29 PARCEL 271 001 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 X�5 A5
Typeof Construction: ERECT 10 X 12 SHED INSTALL REPLACEMENT WINDOWS& SIDING
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure -
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 Csion
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.
BP-2007-0062
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit Buildinq
Category_ BUILDING PERMIT
Permit# BP-2007-0062
Project# JS-2007-0101
Est.Cost: $3500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 15071.76 Owner: PRATT LAURA A
Zoning:URA Applicant: PRATT LAURA A
AT: 71 LONGVIEW DR
Applicant Address: Phone: Insurance:
71 LONGVIEW DR (413) 585-9588 O
FLORENCEMA01062 ISSUED ON.7/27/2006 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 10 X 12 SHED, INSTALL
REPLACEMENT WINDOWS & SIDING
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 7/27/2006 0:00:00 $50.00825
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo