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" DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as his/her construction sups: , 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 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 the work can be ins ected.
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
pip
F ti� (rii of �Out
(� 1It}�fn�z 1----_
DEPARTMENT OP QUILDD\)C INSpPCTlOi,,s -
212 Alain Street Municipal Building
Northarnpton, Mass. OIOGO
«rO'MCC IZ'S CONQ'ENSATION MSURANCT- AI,'FInA`rI-1-
01 CCaS-cC/pCTMJ acc)
prbi lcipal place of business/residencc zt:
3 L C&Q �-�_ s (l
do hereby certify, under the.pp.i is and penalties ofperJury:,- .1h:l
( ) I am an employer providing the follo.vine works comoens�:jo, coverage for lny
1
employees worldng on this job:
1
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- (Iasar-n=Comr-.c.•) CPcCIC- Ku-mbcr) -- (';-pirztion Dal--)
'I
( } I am a sole proprietor, general coon-acxor or homeowner (c cie oee) and Lave hired
the consaciors listed below wbo have the '10110%"V 9Q workers GOC7etL�2t7On pakies:
([+flIDC
Of CO:,=C-,Or) (Instrancr- Companyi-PoGc; ?�rl1fI1_C) �xJIFJ Q DaIC)
i
(N;me of Coamaor) (Ins-ura_occ COMOa N-1polim Namcrr) 6 o n Dat e)
(Name of Connaaor) Claw--ancc Company/PoUq- NasbJ) (Expir doo Dacc)
(Name of Conaactor) (Lasvranc-- Compa.n-y/PoLcy Numb:.r) (E�p11 a1 Darr).
(sauh AiCCCSI 6�,:,if nccairy to inc?uc�iaCor�u.�oa pcZainyug to.11 msr-to:z) .
/I am a sole ro netor an Lav
P p a e no one working for me.
( ) I am.a home owner performing all Lbe work myself.
NOTE:plesc be ewxrc t*_e ktJe hemeoµacn u �GIoY P�roas to dJ c. -e c rcpzo war-k on L of
ant m th:.n Lb =Aj is which the bomoo—oe=raada o0 oa tb c p-oun6 nea:rs tbeaa ox L e-,Uy oec::daai to be
emplo)-s und the.=kcr4 x=::p�oa Act(GL152=i(S)),:pp[iatsoa by a bomeoava fcr:Gc=:_or pCrM;I rty e-dco=d-'e
1''Sil.w.0 oC ea ea�loyor uodcr dro Workol.Coat/ az yioa Au_
[uadczti d tba x copy of this mt®mt m.y tw Cor,urdeC to the rin&itrid Aoad=sl OT,—oC lra�ror U1
-circuioa o'rd th_t Ld. -to sc ,co%'�=6--sxtioa 25A cf AMOL 152 can icd to tlx zupa oa o(a-imiaal paulric
�
. of a Gne oCttp to SI}00.00 utd/oc i=piioomc=o(up to ooe ycr e.od a%il pcaxkjm in do form o(a Stop Work Order and a
C=of 5100.00.dty tPinA me
For dc�.rtm±.il�•<only
n permit NUmt)CS
St( �turr of LtccJPcrrrtiucc
LA
ce — L401
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: �O l..J ��� �d
�cense Number
Address � � � o �..� Expiration Date
Sig re Telephone
r � r �
.Re'istered'fom¢.Frn`ra�zemen .Co�tracfo '� �_ -�� ,.s; a : aj Not Applicable .❑
Com an ame Registration Number
�� P-� - o
Address (� T , ( 1 Expiration Date
Telephone(d 0-3ckl,
SECTION 10-WORKERS'COMPENSATION,INSURANCE AFFIDAVIT-(M:G-L,c.152,-f 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 buil ing permit.
Signed Affidavit Attached Yes....... No...... ❑
IN M21
W )1 )lI >
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,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
r .
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check aftaoplicablel
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing Yr
Or Doors 13
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [p Siding[o] Other[❑]
Brief Deqgiption of Propose Q p
Work: Prw\s�V � �
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa tf New[of iserar�d' c ditrali to exlst�ncr�iOr sl a compre i o aut r�rcl
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-;OWNER,AUTHORIZATION.-TQ-BE,COMPLETED-,WHEN,
OWNERS-AGENT OR`CONTRAGTORTAPPLIES FORT BUICDING•PEl
Y'\S O as Owner of the subject
property
r
hereby authorize
to act on m behalf, i all a relative to work authorized by this building permit application., �d utl-Signature of Owner Date
I, b 1) as Owner/Authorized
Agent h eby declare that the statements and inforninattion on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signe under the pains and penalties of perjury.
W
Print N e
®—N
Signature of Owner Agent Date
'
. °
,
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 Special Perm it/Variance/Fndi ng ever been issued for/on the site?
NO 0 DON7 KNOW 0 YES 0
IF YES, date issued:::
IF YES: Was the permit recorded at the Registry uf Deeds?
'
NO �
DON7 KNOW `ES
IF YES: enter Book | Page! and/or Document#;
'
�� ��
B. Does the site contain ubrook, body uf water u,wetlands? NO �~��� DON7KNOVV �_� YES �~�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tmbeobtained ��` Obtaino� v�� Date
�~� �~� ' .
C. Do any signs exist on the propert �� ��y? 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 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre oriuit part me common plan
that will disturb over 1 acre? YES ��� ) NO C��)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
* ;TM�
City of Northampton Statttsafr�'"eiit � �
fi l
Building Department % fly �e s
w. t"
212 Main Street sewel't �ra(IaII
, t
Room 100 1aterfe ��ab�I4 .
Northampton, MA 01060 m ate°
phone 413-587-1240 Fax 413-587-1272 Pos1?�ans a
M �m
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITFEINFORMAT.ION
1.1 Property Address Thit section to be completed bgoffice
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MaP dot Unrt
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\ f, Zoe Oue lay�Dtstnct
l� r--��^/t C EIi St Distncf Gt2isfFrFt
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED-AGENT
2.1 Owner of Record: II//
raet Current Mailing Address:WO
Teleph ne
orized Agent:
� l-4 nt) Current Mailing Address: O' 9 t� s�. ---i � �Telephone
SECTiON.3-ESTIMATED CONSTRUCTION:COSTS,-
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (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
6. Total=0 +2+3 +4+5) 0 '0 Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/inspector of Buildings Date
�x BP-2007-1040
GIS#: COMMONWEALTH OF MASSACHUSETTS
00` 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-2007-1040
Project# JS-2007-001674
Est. Cost: $6500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin BOB THIBODO ROOFING & SIDING 152172
Lot Size(sq.ft.): 17249.76 Owner: JOHNSON ANN D
Zoning URA Applicant: BOB THIBODO ROOFING & SIDING
AT. 9 HICKORY DR
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527-7663-0
NORTHAMPTONMA ISSUED ON.5/1/2007 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 S nature:
FeeType• Date Paid: Amount:
Building 5/1/2007 0:00:00 $25.003063
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo