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6 DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '
Northampton,MA 01060
oe
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as hds/her construction supe:.,isor. 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 hour), 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
i d
understand the above.
ome own esi ent's signature requesting exemption)
call to sc ule all required building inspections necessary for the building permit
su to me.
Date
Address of work
location
k
e _
1tN-fP -
of �,\Tayfljalliptnll
•!1 6 f�.'1�iaa ACh SIS[lla
r DEPARTMElrr Of' BUILDING INSPECTIONS
212 !Plain Street ' Municipal Building 'o
Northampton, Mass. 01060
WOPJCI✓R'S COMPENSATION I SURANCE A + M AN1.T
th a principal place of busiIICsshts'deIlCe is
do hCrCUy CCI--LlI}'• L!n:ICI" the h !i1S 3.nc pC it It1CS ni p`;r1111 '.ha:.
( ) I am an employer providing the coinpens tlon coverave for lny
employees working on dils Job: v
(LB-T C:2C CoL pap) (•of C:1VtiL^li be r) --- 1- �il l�]Date)
( ) I az-1 a sole proprietor, v',erlerat honleowoer
(circle one) and ha',e hired
t.l]C contTactors listed below tht i61.1iG ^'D wor kc,`s co lms :on
Q,Ia c of Contactor) (1S1sL ti,iC^ NL13I7 I) T? ICi. Dal^)
(Name of Contactor) l\ u b--r) (1 `:':r2i10 Date)
("fame of Contractor) In;lr nc� CoL ;:an}iI'oli� NLUi�b r) ti;,:r oa Datc)
- (Name of Cont-actor) -- (Iosz ranee Cotnr i.�;�I'olicy Numi;�r) — Date)-
(F:;:p
(ntLidi:.d•!itimil r;cct i`t:c.-�.•,r::n:r::'�-.. ,. -K::utiot:;�_._..:irr,'.-:.i;c:<:r_d:::-)
1. 1 iLlll
it sole proprlt° Oi 211;1 have 110 one •.'Jr�iii; fo; n1 c.
j iI] a home ov"n-l" iiCi:O"I111I -ll i1. v. , ... iii' sClt.
NO TT.:plc u be ati.a e if;a a�•ile kx;co.:zr :.rJ C. )lily ii.� 2 4:'. a_�IlSZ1C�cL::CtJC'Y] -r:Ly lit
not uxre th:a throe unis in\%t-cdl;he k .+;aZr-rn::;:a or a;` �:'::s: t ~<r rS Lhcc o :t nx�ersally ate::: :o t�
cn,ployc3 u.'xcr t}r Iwti:cr'a cc:x.---: i-a:r.(oL!S�Ys!(51;,-,:r•t:.�;ic:;by a k:n;:tro:l-,cs'or a L•cci;c c�p:r;:i:- ...'tr,�c t...
legal etatur of an employer under tun Wcvi;cla t o ec:.litm!.cL
I unde_-riand tha:a cm?y of th:x date.-'+-•r:ay bo fo,—, tivd to ti»IYtwrtzrsat of IndustriJ xl&�r.y Chao of for tlx
coverage vrrif calioo and that f_ilurr to: auc cov ro ut 3:zc�.i 25A of MG1,152 can It--,d to the intr-'sifion Of cr ni^.l pctlalt:ca
cvmisting of a fin,of up to S 1-500.00 an.'Jcr of up to cr..} ..:.1 civil perultin in t-c form cf n S!"'ti'ai:On:=_:-A
fn--ofSIDO.W Idayipain:.ltn:.
"r ord,a:uumtsl u.o orlly
perrnit Ntunb:r _`.------•-----•-
Signature 0 f
� � �n
€��N1 CA 4. UZTION SERVICI=S p
8.1 Licensed Construction Supervisor: Not e ❑
Name of License Holder
Li se NNUber
Address Expiration Date
Signature TeleplRone
Eflumm 66HIF ac: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
CTIO� IV,a ERS.' COMPENS#ION 1NS�URANCE 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 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 15') (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 and L Q Laws and State of Massachusetts General Laws Annotated.
Homeowner Signa
a
HE
O P D I�ROPOSED WORK c tCJ(aJI W Mira to
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ J Other [ )
Brief Description of Proposed Work: C r //
Alteration of existing bedroom Yes N A ding rfew bedroorK Yes No
Attached Narrative❑ Renovating unfinished ba ent Yes No
Plans Attached Roll❑-Sheet
0 0 ,i"tion o rsin"g"` ''!Muging.cop a eI .ow ng
a. Use of building: One Family Two Family Other
b. Number of rooms in each mily unit: Number of Bat s
c. Is there a garage attached?
d. Proposed Square footage of n 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. f wetlands? Yes No. Is construction within 100 yr. floodplain Yes No
j. Depth of basement or c ar floor below finished g de
k. Will building confor to the Building and Zoning reg ati.ons? Yes No .
I. Septic Tank City Sewer Private wet City water Supply
l H W
RATION Ox
TBE COMPLETED HEN
APPLIES FOR11L°DI(J�G PERM1
,,;
I, as Owner of the subject property
hereby authorize to act or
my behalf, in all matters relativ work auth ized 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 r'
Side L: R: L:_ R:
Rear
a'
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parkin 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 record at the Registry of Deeds?
NO DON'T KNO S
IF YES: enter Book Pa and/or Document #
B. Does the site contain a brook, body of wat or wetlands? NO DON'T KNOW
YES
IF YES, has a permit been or need o be obtain d from the Conservation Commission?
Needs to be obtained Obtained Date Issued:
C. Do any signs exist on the prope y? YES NO
IF YES, describe size, type nd location:
D. Are there any propo d changes to or additions of sign\innded for the property?YES_
No
IF-YES, describe size, type and location:
City of Northampton
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 D OAF pWELLING
I �
SECTION l -SITE INF011" ON �.� �- 2
r
1.1 Property Address: tfic oaf
6'
•
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!
Eltt?St�Distrtct CMBUts rtct ��'�.,:,
SECTION 2 PROPERT' OWNERSHIP%AUTHORIZEDAGENT
,.:;;
2.1.0w.mer of Record: .
h/ /C/Z"e IAe:
ame(Print) Curr Maili g Address:
Telephon
ignature 211;! 1 ° 1� �
2.2 Authorized Agent: . �`
Name(Print) Current Mailing Address
Signature Telephone
SECTjONR3` ESTi`MATED!CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use!Orly
com leAed by ermit applicant
1. Building (a) Building Permit i ee
® D
2. Elec':rical (b) -Estimated Total!Cost of
Construction-,.from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVA
5. Fire Protection
6. Total = (1 + 26 3 + 4 + 5) Check Number
This Section For Official Use Onl
i3uildtng=Permit-N
Urn ber: Date Issued:
Signature:
Building Commissioner/inspector of Buildings,, Date
� W
BP-2004-0066
GIS#: COMMONWEALTH OF MASSACHUSETTS
s9 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0066
Project# JS-2004-0101
Est. Cost: $1200.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 69696.00 Owner: WALKER PAUL J&ALICE A
Zoning:URA Applicant. WALKER PAUL J &ALICE A
AT. 52 GILRAIN TERR
Applicant Address: Phone: Insurance:
52 GILRAIN TERR (413) 584-2022 ()
FLORENCEMA01062 ISSUED ON.7117103 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT 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 Occupangy Occupancy Si nature:
Feel e: Receipt No: Date Paid: Check No: Amount:
Building 7/17/03 0:00:00 7030 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo