35-198 (5) g�t1A]KP�.
•�,O Oy
of 'Warthampton
$ � �Gi isssxc3�iisctts _
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 780CMR 108.3.4 to
act as l:is/her construction sup,.:•.•i sor. T he state defines "Homeowner" as, ".Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fami --
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 iegulations. 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, L Z 0,G (2 G P s,�r,� ��/.0Lr_4 t.,_Atnderstand 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 r/t a 13 0912 i0/
r
Q 12 Ir All
4tiwr�r _
0
F fl Q f j l I f-�) of (No fljalllpfol1 - _ —
g E glasawchr rcIIa' —
DEPARTMENT OP DUILDr)\'C INSPECTIONS
212 Train Strcet ' Tfunieipal Building
Northampton, Mass. 010GO
- WORIa-RIS COMIENSA-EON MSURACE Al=A.VIT
(li ccusxlpctmi flee)
%IrIth a principal place of businessfresidence at: _--
(phone:')
(Sur--U ity/sta.tcrap)
do hereby cerdfy, under die p?-ins and penalties of penury, thai
( ) I am an employer providing die followine'woriccrs comocnsabon cove mSe for lnti
etnplovecs working on this job:
(Lasut--n=Comr,�) (Petie:Nu-mbcr) -- ( :-piratior,D2L.)
O I am a sole proorietor, general contractor or homeowner (ci:cie one) and have hired
the cona-accors lister below wbo have the `ollowv cq workees c=oensauon pabcies:
(Nmc Of Conl7n ior) (IRR'r311c;. Colnoa yol Guc y (CJIaluon bate)
-- (Name of Cootraor) (lnsutanec ComoaaviPoUm, `umcrr) (Expiration Date)
(Name of Coaa-aao;) (Insuranc: CompanyfPoUcy N;Imbu) (Expiration Datc)
(Name of Contractor) (Iasuranc–c Comeany/Poticy Num)y`.r) (Expirz6on DaLr).
(at 41:ddiZ:0=j r.s'cct,ifncc—ry to ircu%&�'iafocmAEoa P=-ti ni.a6 to..0 co=-CLOra)
( } I am a sole-proprietor and have no one woridog for me.
I am.a home owner performing all the work myself.
NOTE:pl=c be a lre 0 +1 ]c hca:=o.+=n•to em=ploy pc=.<=to 63 c tgau�oric on.d`,,cjl of
aot mote th=t tree Mara iu ulaich the bomoowmcr raid=oc oa tb.c gouo6 na C=rlUy o='d.-=d In be
cispicycs trndc the ktzi eta c�-x--..;ca Act(GUI 52.=1(5)),r pptic3Ecz by a boa==fcr:bc=-Or Pamit r=y c 4dco=trc
Ic-PI er�-su of en e=:ployec under dro WO kOec Cocapamalioa Act
i uoz___d ds.t a copy of tbi.mtemean m.y b.foe xnrd.d to the Degartmma artodaa5riel Aendeao'om-of bay roc tb.
covcra.sc vrrWc=Lioa a.-Id U=i f_iltac to scsuc'eov,z under scciion 23A dMOL 152 m Iead to the ia'PO"doa of :n.;n.1 pccilW= -
coawur g of a rise orup to S 1 X00.00-1000 6=Pri3oamc=of up to one y=r ead c%it peaaYi=io 6c form ora Stop Wort;order and a
Fl=O(:S 100.00 a d=ay a&Aia'A tDC
. For dcp.rta��u,c only -
G� Pcsmlt Ntunber
s'iicurc�o a ¢"
all
SECTION 8-CONSTRUCTION SERI/ICES i
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9 ai eere"' ."bafe`lino emeo t a s Not Applicable ❑
Companv Name Registration um er —---
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFF,IDA1/IT It( .L 0.452,,&25C(0
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...... ❑
a
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
SECTION 5--DESCRIPTION OF PROPOSED WORK(check-afFapplicable)
New House ❑ Addition ❑:. Replacement Windows Alteration(s) Roofing
Or Doors I—I
Accessory Bldg. ❑ Demolition ❑ New Signs [C]] Decks [p Siding [EI] Other[CI]
Brief Description of Proposed s T
1
Work: /'J?/ �,'T Z JQ I� l 1O
Fe 4 .,C 7 �
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
„xr .E 'a'e "tzr -„c,.s^" �`��.,-::.:.a .:s,..a 'M-9-.T�''°' _°,; 6-;xn.3 r _. -`nF' —%n
sal f Nero i`btrs6,"n#` -oi cl>tr fo eac inc-t, ,CaMP et��hRnd ld w:
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
L 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 AUTHORIZATI54-T O BE COMPLETED,.WHEN
OWNERS AGENTbR.CONT.RACTOR.APPLIEIS:FOR BUILDING PERMIT..
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 L� G .5 A9/v/J A9 ' Z 0 G a G � f � as Owner/Authorized
Agent hereby declare that the statements and information on the foregoi g application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury. ' /
C.. 0 6,19 Ci c
Print Name j
a
Signature of a gent ate
Section 4. ZONING All Informatioh 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 ? I I
Frontage I
Setbacks Front t_s —
Side L:l , R:l L= R:= � r
Rear
Building Height
Bldg.Square Footage j I I % —� i---1
Open Space Footage %
(Lot area minus bldg&paved
parking),
#of Parking Spaces
Fill:
(volume-&Location)
If
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES Q
IF YES: enter Book i Page' Document#i I
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Date Issued: f ?
C. Do any signs exist on the property? YES 0 NO 0
f
IF YES, describe size, type and location: ��
D. Are there any proposed changes to or additions of signs intended for the property? YES NO Q
IF YES, describe size, type and location:
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 O r NO 0
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Coy of Nort ompton
r � rc, F,� , Fc� '1'g Department
` 1�2, Main Street
Po om 100
C, , Nor+tf pton; MA 01060
s: hone 413-�- 240 Fax 413-587-1272
I )�P,FWCAOON TO CONSTRUCT�ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE'INFORMATION
Thjs sect►on to be comptetedl bxofftce
1.1 Property Address: //►�
�A 121V Zone Ouerla7r Dtstrrct'
01/ 062
ix .�
ElimSf D�stnct 'n� `, CBd�str�ct "' s
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT.
2.1 Owner of Record:
51 i4fagL' 1' ' S�N/7�Qr� L0CcGPZI5-a i4L>leT5 P tZo, /Y/�, Q a
Name(Print) Current Mailing Address: /r J O
Telephone (n cF
gnature
2.2 Authorized Agent:
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
o o /5 G1AC7 7a�
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee.
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number f j
This'Sectian For Official Use Only
'Date-
Building Permit Number'= Issued:
Signature:
t
Building<Commissioner/inspector of Buildings Date
1152 BURTS PITAD BP-2005-0321
GIS#: COMMONWEALTH OF MASSACHUSETTS
MjV:Block:35-198 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-2005-0321
Project# IS-2005-0419
Est. Cost: $1400.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor. License:
Use Groin Homeowner as Contractor
Lot Size(sg^ft.): 11543.40 Owner: LOCOCO SAMUEL J&SANDRA E
Zoning: SR Applicant: LOCOCO SAMUEL J & SANDRA E
AT. 1152 BURTS PIT RD
Applicant Address: Phone: Insurance:
1152 BURTS PIT RD () 586-6460
FLORENCEMA01062 ISSUED ON.
TO PERFORM THE FOLLOWING WORK:INSTALL PELLET STOVE
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 �//,o 4� 3493 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
1152 BURTS PIT RD BP-2005-0321
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35- 198 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-2005-0321
Project# IS-2005-0419
Est.Cost: $1400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as ContractoC
Lot Size(sg.R.): 11543.40 Owner: LOCOCO SAMUEL J&SANDRA E
Inning:SR Applicant: LOCOCO SAMUEL I & SANDRA E
AT. 1152 BURTS PTT RD
Applicant Address: Phone: Insurance:
1152 BURTS PIT RD () 586-6460 (�
FLORENCEMA01062 ISSUED ON.
TO PERFORM THE FOLLOWING WORK:INSTALL PELLET STOVE
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:O'A' IzV
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATI S.
Certificate of OccuQancy Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 3493 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo