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DEPARTMENT OF BUILDDNG INSPECTIONS
INSPECTOR 212 Mann Street ®' Municipal Building
i
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 1083.4 to
act as !Js/her construction sul". : :,sor. The state defines "Homeowner" as, " Ierson(s)
who owns a parcel on which he/she resides or intends to be, a one or hvo 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
understand the above.
(Home ner/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
r
location s Z.. tm-'iii e-a 4��
212 Alain Stt cct A1t atcll,.t1 7>ul lint;
No thaml)top, hkss. Q10%
\VORILI�R'S COMPENSATION INSURANCE AITFID: IFF
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t .i :CI; �-�.t_ ,. -, _, �..i' � ,�•iiG 1)C;:Y,ilili. '.� `111;
i?pioyl pro'.']! in he Mo`.,'lll; Y
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1 X7;7 ci �,O�C pyUp cyn t't.il` C l cannac o. An Lc e"),"vI
t`...� LCI?._?c tc)Is iS?CC l 70 have the P, , C� k_ _ , _, _-_ . - I
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DW
(Namc of Conuoctor)
(Name of(_onvacWT-) (IIl U17IIC
tx 1 hill it .;u�c havc no olic 1ol
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ccA 11Kcc llan ducc u::rit 1:-, cxi 11,.- _,ai ..,�t tbr_.,.:..c n.;c f,.�r 11, o_•.. h..
c;:plo}mss utirr t}r%tr:Srl'l Ac:(61,152,--s 1(5))..
1cgal ciztut of art Q:��lo}'a un�'cr 1,`:n Wor 4ccic l,o,•>;{wralioca r`.ci
I undcnt..nd di.t a copy of lh�Ca1r1:�:I nay bo fawnrctod to t};.�L}-_txu LZx<a:of lnd,;-i1nJ MiG.nt� (Sic
covcrnsc vaif'ic-Lion Pad Out L•ilt::c to 25A cf MC-1,152 can Icad to tl ia;;xisific4t �:-��:'I Ixrsll_cs
c"n sting of a Slim of up to of up to c:'.-}u enj avil p ru L'ic in
fir>"ofSl(�.(X) a<ity■S;'.in:1[:r_
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address
y/
Expiratio, D e
Signature Telephone
9 Registered Hom"e�lrrip Ctr „y Not Applicable
rovement on actor
Company N ame Registration Number
Address Expiration Date
Telephone
SECTION 10-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...... j
11 `�� IommeOAyner Exemptzon
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, Stage nd Lo I Zoning Laws and tate of Massachusetts General Laws Annotated.
Homeowner Signature
t
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition X Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks Siding[ ] Other [
Brief Description of Proposed Work�i A /
Alteration of existing bedroom ___Yes No Adding new bedroom _ Yes __-- _ No
Attached Narrative N Renovating unfinished basement Yes __V No
Plans Attached Roll [.I - SheetA
6a, If New,h'ou'se and`or additi6n to existing housing, complete the following;
a. Use of building : One Family_ Two Family, _ Other
b. Number of rooms in each farnily unit __6 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. _ _ Maschec'k Energy Compliance form attached? - _--
h. Type of construction
Is construction within 100 ft. of wetlands? Yes _ iJo. Is construction within 100 yr. floodplain _—_—Yes _ J` c
j. Depth of basement or cellar floor below finished grade
k Will building conform to the Building and Zoning regulations? X - Yes -__ No .
I. Septic Tank City Sewer Private well City water Supply—_ _-
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I
--- ---------- -_-----__—, a s Owner o f the e subject P o
' Per,,,.
hereby authorize to are; 01
my behalf, In all matters relative to work authorized by this '1nrilding permit application
Signature of Owner Date
I,
as Owner/Authorized Agent
_
hereby de re 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.
Lin e u e of er/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 _ J�l� 5
s
Frontage ;i
Setbacks Front U �
Side L: R
Rear 's
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 DON'T KNOW _
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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: —
Dep trent�useortly �m
City of Northampton Status of Permit �� � w a
BUiluing Ddartment Curb Cut/Dnveway Permlt� '
212 Main Street Sewer/SeptrcA arlabillty �
Room 100
Northampton, MA 01060 Two Sets of Structural Plans � 3
h
�lgone 41 3-587- 240 Fzax 413 5Q 1.'?:__ Plot/Site Plans= n� i
Other Specify 4
L
APPLICATION 1-0 CONSTRUCT, ALTER, REPAIR, RENOVATE OR DENiOfas PA- N--E'p , ,IV(1 i DWELLING
-- - ----- L� l_z U kY LL ----
- ---- —
SECTION 1 - SITE INFORMATION APR 6 2004
Thi` section to be corn leted by_ffice
1.1 Property Addrt ss: p
.
/ ' P1 tit �
ap ----�'t�qk nit
�2)f� �`��� Zone �� Overlay District
�_��_ Elm St. District CB District___-_
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�j -- - - 6
2.2_Ru_t_horiz-ed Agent:
rr-<,5
S
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
�tem Estimated Cost (Dollars, to b�� Official Use Only
- completed bvpermit apc)hc ant ` — ----
G
5ui n� P'ilding Permit Fee
_i
I � :ted Total Cost of
cristruction from
Building Permit Fee
� I
t
5 '-'i e f rotec"lor
6 �tu �1 + 2 ; + 4 + 5
--T----- -- L-- --- �J ��� -- —_LCh ck Number
This Section For Official Use Only _- -
Building Permit Number. Q Date Issued:_____
Signature; ----
I --- - - — ---- --
Building Cornrnissioner/Inspector of Buildings Date
a
I
w#BP-2004-1011
APPLICANT/CONTACT PERSON ANDREW DOUGLAS J&
ADDRESS/PHONE 89 LONGVIEW DR FLORENCE 584-1370
PROPERTY LOCATION 89 LONGVIEW DR
MAP 29 PARCEL 273 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 10 X 10 MUDROOM 12 X 24 DECK& 12 X 18 SHED
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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF94MATION 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 mmission
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.
89 I#NGVIEW DR BP-2004-1011
GIS#: COMMONWEALTH OF MASSACHUSETTS
MaQBlock: 29-273 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-2004-1011
Proiect# IS-2004-1507
Est. Cost: $2500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 15071.76 Owner: ANDREW DOUGLAS 7&
Zoning.URA Applicant: ANDREW DOUGLAS J &
AT. 89 LONGVIEW DR
Applicant Address: Phone: Insurance:
89 LONGVIEW DR (413) 584-1370 O
FLORENCEMA01062 ISSUED ON:4127104 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 10 X 10 MUDROOM, 12 X 24 DECK &
12 X 18 SHED
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 OccuiDana S; nature:
Feel e: Receipt No: Date Paid: Check No: Amount:
Building 4/27/04 0:00:00 1647 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo