29-074 (2) 4� A
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` DEPARTMENT OF BUILDING INSPECTIONS
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 sup(:-:i 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
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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DEPAtRTMEIJT OP BUILD0\10 INSPPCTiOI.'S
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212 Main Strcet Nfunicipal Building,
j Northampton, Mass. OIOGO
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WO TUCE R'S C O i1IT E N S A'I'I O N LN S U�CE Al,I D�A TF
9,�L s��,� IJ Cr � --�'ry
01 ccnsxJJpcm-�ticc)
%=.nth a principal place of business/residence at - ---
e2i A /I�(�12�7-4,4 y" O� (phone') --g6 —�1L�7
i (stra ty/st=lzip)
do hereby certify, under the pains and penaities of perjury, hat
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(f,I/I am an employer providing the follo%vinu-workces cotnocnsabon coverage for Illy
employees woriong on ties job.
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Qnsuran=Conraml) (PoLi c: Nur—Zb-r) {F_:pirztior,Date)
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( ) I am a sole proprietor, general contractor or homeowner (ci cie one) and have hired
the conuactors listed below wbo hzve, the followv opz worker's policies:
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01+3ID: a- Co„^cior) Ons-umnc;c Cornolrl)./Pouci NtUnt=rT)
(Namc of Coat vaor) Gns-a=c;. Comoaz”-/Poljc- \wncrr) (LYDir,-ion Daie)
I (Mane of Conraao ) Lxpirteo Dam)( u v
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(N me of Contractor) (Lasurana. Comcazy/Poliey Numb-r) (Expirtioo Daft),
(aaau+ Deal rbcd,ifnc�a}-tn adu�iaforna�oa pnaiaia6 all oo=—_c,)
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( ) I.am'a sole proprietor and have no one world.ng for me.
( } I am-a home owner performing all the work myself.
NOTE:plese be cazrc 0—Ii Jc bomoowvcrsµbo clay pcsoai w do -, c=—=jao c mac w•oric va.d.,c11=S or
not n]ort 1�--a Lbra =rj in«-bkh the borno,.cr raid=or oo th,pvuncS zapurtea_a tbcrr o�- oa C=�.r..Uy oeesd=d w be
eirploycz unGr the..vi a':c=P==.:Iim Aa(GU1 S 2-=1(5)�:ppUa.6oa by a bomcoa-oa rc c 6c=--(z Pe-nnn rr_y c%cdco=tf:e
Icgs.l n or na e-;rloyec uoder dro Woke.Coarp omalion A.L
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I uodcrzand that a copy oC thi.mt.emst may be foc�.nrded to ttw popertmao¢of Io�asaiJ Acedr��()trios oC Gss;<+r.ncn for t6.
covazsc"mf es3ioo nerd t2u L-iltac w soauc tovaryse antic uxtion 2 S A of?.toL 152 m led to the iz�irioa of eimina!pcailtic
oomL+mS of i rine of up to S 1 X00.00 and/or iapris�orup to one year r Dd Cj%-U P=aLrja io d.room of a Slop W.+Ord-aad a -
Gm 0(:S 100.00 t d y tpins1 UY-
jFor d 1-r u,c only
Permit Nttmbcs —
Lf Loth
SignaWm of LiccnsccfPcrmiucc —�� J
SECTION-8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ,pu>>N
License Number
5l
Address ? Expiration Date
® A ' ,e 0,_a 7° aav b
Signature Telephone
9: teats ere" omeilrnnrc>'sreineriContracfo Not Applicable ❑
Company Name Registration t�um— - -
7 9 e gAr 120 1-,,) 1O0416 -)
Address �-y Expiration Date f
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Telephone.��� `J7�i%� '/�j�ap0 4
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SECTION 1:0-WORKERS'COMPENSATION 1NSURANCE,AFFiDA-4 YIT(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 buildiDd 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-vear 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
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SECTION-5-DESCRIPTION OF PROPOSED WORK(check'all applicable)
New House Addition ❑. Replacement Windows Alteration(s) Roofing
Or Doors O
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [0 Siding['01 ] Other[O]
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
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Elk
sa`if euF housend Qrddit�a txcextsnroaslnct :omileteIie fo�louu�nn:
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 AUT-HORIZATION-TO-BE COMPLETED WHEN
OWNERS AGENT'OR CONTRAC TOR°APPLIES FOR-BUtLDING.:PERMIT-
I,✓ S!1' s j 14 b44 d� as Owner of the subject
property
herebuthorize �W
to ac 7,1n behalf,in all matt relative to work authorized by the building permit application.
�y Al
Sign ture of Owner Date
as G~eAuthorized
Agent hereby declare that the statements and informatioh on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
w J Ai �3IZA0
Print Name
Signature of 6nwmlAgent Date
Section 4. ZONING All Informatihh 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
1
Frontage
Setbacks Front
Side L: R:' L R:I
I--- I
Rear
Building Height
Bldg.Square Footage % —
Open Space Footage %
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(Lot area minus bldg&paved L i
parking)
#of Parking Spaces
Fill:
(volume,&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:'; I,
IF YES: Was the permit recorded at the Registry of Deeds?
NO ® DONT KNOW 0 YES 0
IF YES: enter Book Page! 1 and/or Document U
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 0 Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
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: j
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES r NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Building Department
212 Main Street
Room 100
Northampton; MA 01060
phone 413-587-1240 Fax 413-587-1272 wo
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Thrs section to be cornpleed by office
1.1 Property Ad//d--ress/:� 1 '
�, i2 ` !� 206 k INap F Lot r k
N G L Zone Overlay District
Eini 5twDfstr�ct < .-.. cap�sb,ct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 caner of Record:
N e(Pe t� Currgnt6a UAdd//UU reG L MAL S5 ►f -1413.�
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Telephone
Signature
Signature
2.2 Authorized Agent:
/3p-) 42 il0 14
g to
Current Mailing Addre s: /PIP
(Print)
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
2. Electrical -.(b)°Estimated Total Gost of
Construction from 6
3. Plumbing Building Permit fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) l7 p Check Number s`
This Section For Official Use On]
Date
Building Permit Number Issued:
Signature: —
Building Commissioner/Inspector of Buildings Date
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46 ACREBROOK DR BP-2005-1284
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-074 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1284
Project# JS-2005-1714
Est. Cost: $1260.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sg. ft.'): 14853.96 Owner: HARLOW PAUL J&SHEILA P
Zoning:URA Applicant: B & R Siding
_ A3: 46 K:;kc-c�iiivi vr.
Applicant Address: Phone: Insurance:
781 Bridge Rd. (41.3) 586-4167 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON.6121105 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:
Drivaway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Final: Smoke: Final: Qk S'51-11S— .�
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
000� 000'
Certificate of Occu anc ZZ4� SLnatux
FeeType: Date Paid: Amount:
Building 6/21/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo