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` DEPARTMENT OF BUILDI7\,TG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction sups:-. sor. 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 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 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
(ST' 17 Of �;tTI f1J�111l�t011 -
u DEPART MEAT OP BUII-DFNG INSPECTION -
212 Main Strcet Municipal Building —
Norlhamplon, Mass. 01060
WO MCC IZ'S CON'TENSA n0N INSURA-N CE AI^ ,II)Ati'lT
{li�nsa-Jpermi ttcc)
With a principal place of business/residence at:
�f _ (phone:')
� (sa-c..�lci ty/s1.a.Itf�D)
do hereby certify, under the pF-ins --od penalties of per3Ury.; --hal
( ) I = an employer providing the following -vorkcr's coinocns::aon cove2ge for my
eluployces worUng on utis job.
j
- (mS=-:-n=Co or- ,) (Polio.Nu-mbcr) (r:-pin or, D;,,-)
O I am a sole propr;eror, general contractor or homeowner (ci ciz one) and 1?we hi
the coniractors listed below rgbo have the fOtlotvin¢ worker's comoer?"zdon policies:
L
(i+amc, o.COnt^eior) (InsUr3IICC COlrloa,-I)'fhGUCi NLLM*<-) (ExpIiJUQi 0:11C)
(N2mc of Con>raor) (bis-wancc COMDa vlpoI m \' -lunar) (iivir bon Date)
(?dame of Conn-aetor) (Imuraa= Compan)-/Poli-q- NaJnbzr) (Eapir;:aoo Dam)
f ,
(Name of Contractor) (Lasuranc-- CompanylPol;cy Numb r) (EN:p mmz on Danz) .
(aaAch Ai!�ocm.l bccl if to cra!v&iafortn�000 Pa-taiaiag to all
( ) I am.a sole props ictul and gave no one worlang for me.
I am.a home oNvuer performing all the Nvork myself.
NOTE:Plc cc be nw-yrc tic:k{ ye hcmoo�mcn wbo emPloy pcsom to do r. s —e oa c repar war-km a d.•cll Z of
aot snort than ` o:unrj is ubib the bomoa-wcr r.id=oc oa the U-m�x97uncu_r1 the_ z� aoe Car.11y ar- �to Lx
onploy -s stn e the--urns o=zp ,on Act(GL15 .=1(5)�=-;*U=6on by>bomoo-=fez_lice_oc Permit 2y e.ideaoc t-
lcS-Al cL^ of as cployx under d-w Wockcla Coa*oo .boa AeL
I uada-n-and th t a oopy of thi.cw.=-cd r y bo toc>+arded to the Dcpwnm x:a or lnjx+sr;cl At dco%y MOO orlm'^`a°°for tbw
oovea.sc va'i5=;oo=id th1 L-ihac to tccurt toveruZr under soc%ioa 25 A of MGL t 52 as I=d to tbo t of a=iwl pcualho
co=LXi zg of a fiat of tP to S 1300.00 androt of up to ooc yr and coil pea rj=in ttx form of s Stop Work Ordc and a
f=of SI00.00 a day tpiaA me
For d-p�u.c o�1y
/* PCrmjI Numb=
I,,ap-__ Lot
J
Si�,�lurc of LicazstxJPcrm ucc -fie
f
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
8��ea�s�"ere�F3ome �iira�ementi�ontracto "mow % � �::�..
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...... ❑
RN
� - --
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,*Local Zoning Laws and State of Massachusetts General Laws Annotated.
omeowner Signature �l'
e
SECTION 5-DESCRIPTION OF PROPOSED-WORK-(check all applicable)
New House Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [[J] Decks [C] Siding[0] Other[O]
def Description of Proposed n
Work: 'e5 -e 4 /1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa IeWCiorase an d' r addrtlo {toxlsting hou �n�comt�etetieo1fawmg:
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.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a,OWNER.AIIT.HORIZATION-TO BE C.OMP.LETED,WHEN
OVIINERS AGENT OR=CONTRAGTOR:APPLiES:fOR:.BUILDI�IG PERN[1T
1, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized 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 N e
i
SigKature-of Owner/ gent 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 -----7 %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location) V
A. Has a Special Perm it/Vuhanne/Findi ng ever been issued for/on the site?
�� YES ����
NO �_�� D�N7 KNOW �~��
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry nfDeeds? '
��
NO �� DON7 VV KNO YES
IF YES: enter Book Page and/or Document#|
'
�� ��
B. Does the site contain a brook, body ofm/atarorwetlands? NO �_��� DON7KNOVV �~� YES �~�
IF YES, has permit been or need tu be obtained from the Conservation Commission?
Needs to be obtained �~� Obtained ��` Date Issued:
�~� «�� . .
C. Do any signs exist on the prnperty �� ��� 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 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,nr filling)over 1 acre nriohpart ofo common plan
that will disturb over 1 onno? YES ��� � NO [���
|F YES,then a Northampton Storm Water Management Permit from the DPW io required.
e�nt fr
C of Northampton at ►...
B'uilging Department
w
212 Main Street
20 Room 100 OR
BUG Z
MR
Nortiampton, MA 01060
pE hone-41 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -`SITE"INFORMATION
This section to be completed b' affice
1.1 Property Address:
Zone a Overtax DrstM,
lveb
Eirn DiSt[ICt CB D�stiact
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pri Current Mailing Addr
i/
al Telephone
1`i'i� � �C
Telephone
Signature
2.2 Authorized Agent:
Name(Print)L-2 Current Mailing Address:
, x_ -
Signature Telephone
SECTION 3-ESTIMATED'"CONSTRUCTION COSTS-
Item Estimated Cost(Dollars)to be Official Use Only
a i
completed by ermit applicant
1. Building (a)Buiiding Permit Fee
2. Electrical (b)-Estimated-Total Cost,of
Construction from.6
3. Plumbing Building Permitfee-
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number S __
This'Section-For Official Use Only
Date
Building Permit'Number. Issued:
Signature:
Building Commissioner/inspector of'Buildings Date
rt
BP-2007-0212
CIS#: COMMONWEALTH OF MASSACHUSETTS
+` CITY OF NORTHAMPTON
Lot: -001
Permit: Buildinq
Category: BUILDING PERMIT
Permit# BP-2007-0212
Project# JS-2007-000325
Est. Cost: $350.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 12980.88 Owner: SMITH PAUL L&THERESA D
Zoning:URA/WSP Applicant: SMITH PAUL L & THERESA D
AT: 16 HOLLY CT
Applicant Address: Phone: Insurance:
16 HOLLY CT (413) 586-1784 (�
FLORENCEMA01062 ISSUED ON:812512006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR PORCH 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 signature:
FeeType: Date Paid: Amount:
Building 8/25/2006 0:00:00 $25.005308
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo