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c. DEPARTMENT OF BUILDING INSPECTIONS �
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INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
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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 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 occupancv
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
tij of !Nay
,
x 3 1 A C4:15 �
5
F,0 BUILDI?�G INSPECTIONS
212 Maim Street ' Municipal BuilcEng
N'or th ain-p toll, Mass. 01060
1;y()r,jCE,r,1S CONITETZSATION INSURANCE ASFIDAVIT
p-*mcIp11 placf-, of buSI'lrCSSfrer).,*,dciir---
m,4- (Qllone-ir) ,j5 5,A,7
na,
P-"�T�s and pcn�,'Llcs ol pp�jjl,,T
am am employe-i- pro-v14117 Coil]n-c!"SaLon
cluployces wor.�drig unl-1.11s Job:
—6
Nurnbcr) Daic)
P. a sole Ero=�'ctor, "voer cle Oct) and
th-- cot:tractors llster below',-,t0 111,.a C..
-ni �:
'.=c of(-0,lL-mct0r) -- on; Datc)
(Namc of Copnac,,cr) Cc)==---'-1v,,?c.hc-,, NLLmt-2[) ilon Dale)
(Name of Coninctoz-) I U77,:>S.CC Daic
(Name of Cont-actor) (Ias-Liraiicz, Comr, y/PoUcy Nlum✓--r) Date)
2-"d hav'-- tic)
am a home cv"-.-,.
not mccc th--u dirce uniu;-�c,, r=: cc oc
czrploy=}uru�thc%VC6..ez. (G`-152-- (5)), fcr a L-c----o4 c<
lc 6i1 r12zliz of rn c=w I 0)w under tL W cz i cez Co,
th-x co-py ofLfiz,ctzte.--=•Ery 1:. to%h-, i-j Axck.=!y Oiio of for tlx
cov va-iG=Eoc and that Lillurr to Z-:.Z:L,--t Co,--:713-z a.,A dM01,152 can lcizi to O)a il'-P,1 0c`
co---i--4ing of rm,of up to-s 1-500-00 ftn&W L--. O{..;p t-')nr.-} r7.j evil On&==A
in form of
S!-P
of S 100.00 x d--y t giLirrt m--
r
U-1:0111Y
S;,LnAturt of
S1=CT10N 8 ;CONSTRUCTI0IN SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ` jo
License Number
A13
Address 4V Expiration Date
Signature r Telephone d �J 30o�
`' Re i tx e rrt `Contr.`"actor.: •- Not Applicable ❑
Company Name Registration Number
Addre L ,c c� Expiration Date
✓el m jCS }� /b�r� Telephone
$ECTIOKIO WORKERS' CO''MPENSATION!: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....... 19 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. CNM 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"homeowmer"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 Zonina Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECFION5=aD SGR P710W0F PROPOSED WORK(check 11 applicable)
EN-
New House O Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding Other [ J
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roil 0- Sheet 0
5a:��-fi�x1�7"e`w ou e and o additroW-1-6 6 i§Vh__iousing c 1,-efe_t1i"dfffW-M:
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
L Is construction within.100 ft. of wetlands? Yes No. Is construction within 100 yr. flocdplain 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
SECTI0I7a�0Y11 ERAUHORIZATION TO BE COMPLETED WHEN
OWNEkS AGENT O'RCON7RACTOR APPLIES FOR BUILDING'PERMIT
I, A 4 as Owner of the subject property
hereby authorize 4.). nJ L- 175 leA N to acT on
my beKaalf,�in all matters relative to work uthorized by this buildint permit application.
Signature of Owner Date
. I
10 N L A 0 L/ as-G�/.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.
i
Signed under the pains and penalties of perjury.
Print Name 4
I
Signature of CrrlAgent Date
I
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: 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 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT 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:
City of Northampton
Building Department barb LM,%A
212 Main Street ri+rer ptcc�va k �
Room 100 e1lA aim
Northampton, MA 01060
phone 413-587-1240 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 by ote
1.1 Property Address:
t L� Map L'o Unit
/6 , C c }� a l�G Zone'' k Q�erlay DistncE
N G ''
Dm St.District-_,;
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ra m,19 A)t' J`�✓ e" y- /fi r' O 4 l�
Na e(P' Current MaPQ Address:
t � Telephone p
Signature 6
2.2 Authorized Agent: l
Name(Print) Current Mailing Ad ress:
All
S g ature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be . ..,,. Official-Use Onfy
completed bf permit applicant
1. Building di g-'Perm it Fee-
✓
2. Electrical (b)l:Essdmated Total Cost of
.• fr6rn-'(61.
3. Plumbing ididin(A Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 +2+3 +4+ 5) �(} Q-' ;Check-Number
This Seciaon'For Official Use Onll
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
*r •4 a
62 ACREBROOK DR BP-2004-0948
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-076 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-2004-0948
Project# IS-2004-1401
Est.Cost: $9500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sy. ft.): 20821.68 Owner: KOLEMBA EMMANUEL J&
Zoning:URA/WSP Applicant. B & R Siding
AT. 62 ACREBROOK DR
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:411104 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 4/1/04 0:00:00 19241 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo