29-045 (2) .ti
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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 his/her construction supervisor. 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 stn,--re- ^ccessory 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 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
I 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
Address of work
location
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I u_�dcnluad dlat a c?py uIl}::.ctitc:r_:c.1 r.ay bo hxuw�}o.1 to tl:o lYtxv tlx�i:of hxLtstri:J Acd«s:=�'Ci`.Gha of !..,....._a for tho
covaasc vcrif c�tioa a�u1 tict Cailt:.-t to�. ,t:c�«z�ultii:r acC,icn 25A of hfGl,152 czn Iced to tfw i:a{�siliai��;.:��::�.I hcl:�lt:a
ooaaisting of a fin,oCup to S l,SC7.Q0 e:�i'IV c::p riux�ir: oCup to cn-}-u n,tii civil V rultic3 if]:1l i-m oC n
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SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable [I
Name of License Holder
License Number
Address /F Expiration Date
Signature Telephone '7- 1
Not Applicable El
Company Name Registration Number
Addre s L/ Expiration Date
B, I -�w
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....... 04K'' No...... 0
Tk,current exemption for^'homco`nncn^was extended to indo !o Owner-occupied Dwellings Luf one(|) or two(2) families
and m ^^.^w ^u,.�i` bo/uu"^.."/ mu`v_uu/ /"r..," mtouo^�, x*,L . 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 ofland on which he/she resides m intends mreside, 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 buildin2 permit.
As acting Construction Supervisor youi presence on thojob site will be required from time to time, cluiing and upoll
completion of the work f(-,,-which this permit is issued.
Also bo advised that with reference to Chapter |52 (VVnrkom' Compensation) and Chapter i53 (Liability o[Employers to
Employees for injuries ovL'osu|hog i.^ of the :,o &nnotated, you may be liable forp000u(s)
you hire m perform work for You under this permit.
The uodomi&uod^homeownc/' coui6os and aoumesuoponsibi\ityfor compliance with the Sca� 8ui\din�Code,City ot
Northampton Ordinunc�o. �m»o und ioo| Zonin��onx und S�mc o[��xymchvxc/� Gcnom\ Luw� &uno�u/od.
Homeowner Signature
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SECTION 5 DESCRIPTIONIOF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacemen indows Alterations) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding tj]/ Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom --Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet ❑
6a."If'New house andkor`add'ition°to)bki'stih�`,K sinir,:complete-ahe followini:
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
01WNEaS:AGENT"OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Wkopo _ Jam_ � d��Q t �� as Owner of the subject property
l_- to act. on
hereby authorize Ae5�� VJo 12 1 0
my b half, in all atte elative to work authorized by this buil ing permit application.
Signature of Owne Date
J rJ /3-) ,!f�� •-� j _ as Qwrw/.Authorized Agent
hereby declare that the statements and on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
rJ
Print Name _
Signature of.Aawef/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
Side L: R: I.: R:
Rear
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 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 _ 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:
.amity.auf!�orthampton
is it 'Department C b Grt
bin Street
IRS m 100
1Na er 1, v :
JUN 2 0 N01th on, MA 01060 � 5et a
phone 413-53` -1240 Fax 413-537-1272 Ploy/51teP.
OF R{ f I_.
'�G NS r�r Qf,N'S P �Y
!'AY,44"� ��`c —' °M-T, ALITER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to„be completed by office
Map Lot unit
h., q . Zone Overla District
Elm St.'District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Recor'd:: Il
J
Name Print Curren$ Mailing Address-
Telephone ^?
Signature
2.2 Authorized Agent: f
1✓�) ,,,,_11 I i:3 /7_Q _ ell //Ly,�1 y1� //p11 -e A.1
Name(Print) ,✓� Current Mailing Address`
� C li 7
Signature Telephone
SECTION=3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit app licant
1. Building s
/J C � (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 d ( �
6. Total =(1 + 2 + 3 + 4 + 5) ` Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:`
Building Commissioner/Inspector.of Buildings Date,
• M
230014tiRKNOLLSj BP-2003-1192
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lora-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-1192
Project# IS-2003-1854
Est. Cost: $11660.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: B & R Siding 100465
Lot Size(sy. ft.): 11979.00 Owner: ELLERBROOK RAY A&WENDY J
Zoning:URA Applicant: B & R Siding
AT. 23 PIONEER KNOLLS
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586-4167 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON.6120103 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL VINYL SIDING & 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 Occupancy Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 6/20/03 0:00:00 18800 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo