35-047 (3) Grifp of Wart1jampfon ^
� � Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS
Q
INSPECTOR 212 Main Street @ Municipal Building
Northamptom, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as Lis/her construction sull : ,, sor. T he stage defines "Homeowner" as, " Person(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
�n
1 �C� �, rr� `��"�.� 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.
Date cl 8 3�r
T&
Address of work
location 617 �1A K0 Q
(a r GC d y [S_
of Nortljallipf Lill
;ui56N(111t6 C115
j1/1RTML?"-Y OF llullj)Ph G INSPE'CT'IONS
212 101 Street ' MunApA DOW!,
Northampton, Mass. 01060
WORTILER's INSUIZANCY, AFFI-DAV-11,
kith a principal place of busAKSWCOdence at
do hewhy unth", undur the PAS told jwnulw w1w'. pay, W!
1 ,-,j-n2n employer providing the Qhownq - kw's COPITPSMUM, Cove my for My
oll
(j0000001 COMPOg) E)2ic)
1 M11 a sale propAutor, gunM Conlraclet- x (Cilccle One) and love hKed
the contractors listed Mow who have the
Owme of Contractor) AnsumnCO Dat,--)
(Nam: of Couuamoo INSUPMCW
(Name of Consaw OnylMnCs P
(Name of Connacwn HISUMMO DaW
tun it ;,olc ..:IA h."'Ve, n", on"' tot 1'itc,
W nxxc Oun MCC UnAl in Mvdi A,
cgal".W;Karl a Mphy.<=&M so W"kw.Cma—Ax-AM
Tor
jC, PCI,
coverage VCII-ificalion IL:w 01--t failure to!�C,,Irc 25A olM(31,152 can lc_dto 0�1:121POsif I 'n-] -11
Cumstirig of a fine of up EO S I Ouloo arrow k1wWrO7 Ali p to )-:--,M civil,cTu It]C I in de f(cn of
dAy IF:611.-A Irr,
cif nature of III
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SECTION 8-.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : --- -
License Number
Address Expiration Date
Signature Telephone
. d r E
�9�Registered�N'�`m�' ImprQvement�;Contractor. ,�;�"��`°,r; ���,_ ����.. . . ' �,_ Not Applicable ❑
Company Name 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...... ❑
1113. I3o.me ®caner"VIExemWE n
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)famines
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 dine, during and upon
completion of the work fe which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 �,i.iability 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 and Local "Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION, DESCRIPTION OF PROPOSED WORK'(check all applicable)'
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors )4
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: AC
Alteration of existing bedroom Yes __K_ No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes Y No
Plans Attached Roll 0 - Sheet❑
6a. If+NeVir house antl oraaddition to existing housing comp' ete`Zthe"followinj�:
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. 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 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of t'oe subject property
hereby authorize to ac; or
my behalf, in all matters relative to wore autho ized by the , 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
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R:_ L: R:
Rear
Building Height
Bldg. Square Footage %'o
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 YES
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 _� _ vON'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: — --
City of Northampton
Building Department CurbptlD e
212 Main Street
Room 100 Wa eIWei vat
Northampton, MA 01060 Twa Sets of
� ,
phone 413-587-1240 Fax 413-587-1272 Plot/Site Plan'_
All
L� Other#Spec f � '
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section;to be;completed.by,off ice
1.1 Property Address: rr))
�%I w� Kc�a Map Lot
t oEf rl[0 �Yl�} Zone Overlay District.,
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT`
2.1 Owner of Record:
Name(Print)1 Current Mailing Address:
�i, phone
Signature
2.2 Authorized Agent:
I
Name(Print) Current Mailing Address:
Signature :. phone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
i
tern Estimated Cost (Dollar, tu h,-, Official Use Only
completed bypern,!t ropl -
Bwlding 5� �-� (a) Building Permit Fee
(h Jimated Total Cost of
Construction from (6)
3 Plumbing Building Permit Fee
,- Mechanic,�l (HVAC)
5. Fire Protection
6 Total = (1 + 2 + 3 + 4 + Ci)eck Number 0(2 This Section For Official Use Only
Building Permit Number: Date Issued: —
Signature:
Building Commissioner/inspector of Buildings Date
BP-2003-0922
CIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: QuildiinQ
Category: BUILDING PERMIT
Permit# BP-2003-0922
Project# JS-2003-1474
Est.Cost: $3600.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 15681.60 Owner: PRYBYLO ALAN R&MELINDA A
Zoning: SR Applicant:-PRYBYLO ALAN R & MELINDA A
AT. 978 RYAN RD
Applicant Address: Phone: Insurance:
9_78 RYAN RD (A 11'% 584-2680 O
FLORENCEMA01062 ISSUED ON:4128103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT DOOR &WINDOW
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 Ric-
Feel e: Receipt No: Date Paid: Check No: Amount:
Building 4/28/03 0:00:00 1022 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo