29-092 (2) �'itV►Mp�.
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DEPARTMENT OF BUILDITNG 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 h:is/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 rouzh 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
i
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^* m DEPARTMENT Of' LUILDMG INSPECTION'S
212 Main Street ' ?Municipal Building
Northampton, Mgrs. 01060 r�
WOMCER'S COMI TENISATION INSURANCE ATFIDAVIT
(lictirs^ci['�rnuttc^)
NvIth a principal place of businesslreside-nc�c <1-.
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CIO hCreby Ccr-tLI}'; L'L1C1c1 Llle p ills 2iiCl pCil iL1C$ C)i pC;f�Uh', f.Ilil�
] am zin C ll foyer providin- t}1C follo .,"li i; v;O t:CI'S comi)cnsS Uon GUVC:':` C for Ili}'
p
enilplOVCC S wot�"LIIg on this job:
1 ��a
(InssuanG
amp m') c c.Nti nEr r) (r�.Fir,:IS D2tc)
I am a sole proplittor, gtri--rai oon=c`or or hocnecwoer (circle one) and gave hired
t.hc coIltTa=Ts listed `Jelo\-i'ii ho ii" ill . `0} :1% VIOrkel'S Go p°III iOi! ;0!I :e5:
Q-,Ia- 1C of ConLmcior) (nsu nc aiCi: DatC)
(Name of Conti c`to:) -- (Insumncc Co,D"c;1vfP0?1T,' tN'tlzntber) ( ?:Direr tioa Date)
(Name of Coat-,-aclor) �Ins�mnce Co��,:_li}v�'oficr Nuliat�r) '.x.ir�tio� Late)
- (Name of Corimiciorj -- (IC1S 13S1C CeTLIrrYiv!rolicy Num��r) (I::pi-aion Date)
i
( J tLTl I. Ole i)1'C)pI1eL'Ji 2111 ilav' - nD on ..'0 1- f0,,- 111".
I am C? home of"i"ne:- iiCl:i rm111`
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ilOt:I1C(�1lL.D Sl1f'CO L`11PJ to\L{::Cll SY I:Y.Z'+�.tZi7 f^3:.'..'.7!n"CXi't>,-�:':-..]Z:r•17':[;.:I`1 LhG'::C t:C!K{�'C1'I111'7 C<'!'::::_::�:o l�
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It gal ctatun of an amp Ioyor un'u-r tL-Wcvkc1.Coct:,w_- tion A.CL
I uzsdeTi�nd the a emy of t}ii ctatct s•ruy Fn faw,u<ioi to t_'a IYt ert,n:of lnd,7striel AX-r&=&of ioo of for 11x
oovcragc vaiisClioa and that L•iltuc to r-z c co\crn�u:3;:cC110-n 25A of?.tGL.15:czn Ic:d to th> i.,p-Dsitian of r i._1 pa�l:a
cvmisL fg of a firx of up to 51.500.00 n::d'cr i-:,r.-n of::�to cn.}; . ..:.j evil�cruItia in do f(- r of n S!r,, :vc i".<Yu_ 1_
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- I
SECTION 8 COaiISTRUCTIGN SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : �i?�� L
License Number
Add re s Expiration Date
O/?, I� R m f 7-0 YV�✓�
Signature ir Telephone d r 7;Z 0'0
�G J //j,/
Re , e. s om m - Yemen&Con racto= Not Applicable ❑
Company Name Registration Number
I
Ad�drr ss Expiration Date
/G!fj rn Ica jet 4 Telephone UG' AQ 0
SEC l01�t 3A YI(Of2KERS' COMPENSATION ni RANCE.;AFFIDAVIT(M:G:L c. 15.2, §.25:0(6))
Workers Compensation Insurance affidavitp6ust be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance o he 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 buildinE 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 f r 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 v _
� Y
f
i
f SECTIO SR P 01+�0FFR�OPOSfDWORK check )='a I�cablekr
j i x..v�$'ja,'*.°5'�!,r�C» a.r :•?,�r' "xn .,, .� ...", ,. .tea
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roof' g ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ 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 N 9 e _ UN d OR iflion to�existing o`" s-rng�, comp fie f�IIVM
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
SECI®N I�VNR U ,VW..I—FVIW A
COMPLETED WHEN
OW �SJ ?N i�OCONTRACTOR APPLIES FOR BUILDING PERMIT
l�c�ll� D/� �t)
as Owner of the subject property
hereby authorize �iGUil24�J�, to ac;. on
my b alf, in all matters lative to work authorized by this building permit application.
.za �C� v 3
Signature of Owner Date
aster/.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.
�GU ,J C- 75'/P,4,,,7
Print Name
O
Signature of-O"r/Agent Date tl
Section 4.
ALL INFORMATION MIDST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to b'e filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: 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:
Cit of Northampton r .
ing Department
2 Main Street
Room 100
l f�!JG 0 20Q3 N pton, MA 01060
hone 413 587 1240 Fax 413-587-1272 ;t
APT
AAA, jGATi00, , ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITUNFORMA"TION
4
This se ta'a tobe�compl�tebyaffice
1.1 Property Address: g
j2 > t o a 0 (2- p
ma
/��fG N r�� ✓d J4 Zon Ou rl' st
Elm StDistricf ~ yCSDisct
SECTION 2 - PRO.PERTY OWNERSHIPJAUTHORIZED AGENT
2.1 Owner of Record:
lj. zs /),f D �1
N �e(Print) Cf' Ma i1 ,v dds: M/1- . 1
/ el/ 1re
d0 / Tele phone
Signature`
2.2 Authorized Agent:
713 6J 11f'
Name(Print) Current Mailing Address:
Signature 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
7300
2. Electrical (b) ,stimated Total Cost of
Construction:from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC,
5. Fire Protection /-
6. Total = (1 + 2 + 3 + 4 + 5) 1300 Check Number
This Section For Official Use Only
Buiidmg.Permit Number: Date Issued:
LS►gnature:'
Building Commissioner/Inspector of Buildings Date
BP-2004-0197
GIS#: COMMONWEALTH OF MASSACHUSETTS
It-��= z CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2004-0197
Project# JS-2004-0287
Est.Cost: $7300.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq.ft.): 13198.68 Owner. FORRESTALL HOLLY
Zoning.URA Applicant. B & R Siding
AT. 46 BRIERWOOD DR
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586-4167 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:8120103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VINYL SIDING
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 8/20/03 0:00:00 18892 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo