32A-035 (2) Gifp of Xort4amptan z
� � �tdassachusctfs -
iy 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 his/her construction super ,or. 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
a cf'!il e r C4 understand the above.
(Home owner/resident's signature re uesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 9 —&a 0 :5
Address of work
location 71
OQ
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s m DEPARTMENT-F Of' BUILDI) G INSPECTIONS
212 Alain Street ' Municipal Building
Northampton, Mass. 01060
NVORICER'S COMTENSATION INSURANCE A I rMA-VIT
1:'ith a principal place of busiressJre:iidence
------ ----- ---- ----- ---- ------ (ph:)TIC,
CIO hereby ccl-dj}t, L(n:'c1 1lic p li1S ;'.ii7 1)C it 1t1CS OI pc;r�llllr, illi!'
O I ._m an empioyer providin- the ,ollovvinz. .:orr_cr'S compensation coves c or my
emplovecs working on this job:
(Insirancz: Corapam•) eli�.?.';t itrt) ----- (`r�rir rion Date)
l ) I any a sole proprietor, zenPra± cones c or ' r r on eo aver (ci cle one) and 'gave hired
the contractors listed below ,v t,` � !l -
.o ,: „ `1 :1 0
(2:3mc of C0nLInC'L0r) Insar rice ]n: l ?
l Con ;; :t o.tc1 Juln)Yr) `'io- Datc)
(Name of Covn.cior) c71]str nc° Con oa:`'/Pe!ic; Nuntr�r) (E, iI- ion Date)
(Name of Coanctor) OI1S lI1C ( O l ;a�'i/iJQI;�: TvIliLlr=l) \.';�nc- late)
- (Tae of Contractor) — (IDs1:faric- ComT y!Polic-,,' N41mbzr) (I:,:ni-::ior., Dare)
m
C I LIl c SO1C i?1"Ui??1CUi r:il;i IILIVr. no loi ?I:.`,
I <?ill a home O�'i ilCr
NOTE:please tic nu-3rc Lta:.vL-Ie 4;pl.••-• 1, :L>'.2� I:LtL1C�Q.:_.^JC Y CS 1-P.1t7
not mwe than throe univ in„j:-*cdt Lhe I r��.ui,-rc:.:=cc c-c n{(Crsal2y ttr:'t:^c:o tt
cmploya3 u_n?c t}r,vc;I:rt:ar x- ;etirn!-r (Ci1.152�s I(511•: ;ic::by n hn:•_i o„ncr:`or e t ccx cr p:i.:i:- ,..'tir,=e
legal rtazus Of=otnployx unur t:tn Wort;cl[
I underxta d dixt a co,y of t}ix etstc,s_my bo fo x n,io 1 to t r IYt urt�rt of lz dzz3tri el for tix
covay.gc vaif•'ctioo and that f_ilurc to r•ti rc m� r ut 3: caiM 25A of MG1,152 o_tn lad to tlx i-r—Sitim cf cr ir_I pc sl;_a
COO-Iistmg of a ftnc of up to S 1.S00.CYJ n:td'cr i^tnri.r.Z.- of::p to cr:)-7. t.-.j civil p nzltia in do fix7n r.f n S!r `;ti's'.otia ar l
Lrr of S100.00 a day
'-
For dq:utlT1'iYsl L1)C Ctrl}' i
Pcrinit Ntititbrx
Sr n CU
crm;ar.._
S�GT�ON 8 CONSTRUGTIQN!SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
191R-,egrTsVe- e a rnp vement C t ' Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECT O 0 11ORf�ERS';COMPENSATION 1NSU13ANCE .L.AFFIDAVIT(M G •c. 152, § 25g6.))
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...... ❑
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 buildin>7 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 far 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 S f Massachusetts General Laws Annotated.
Homeowner Sign ture '? ?
SE TION ES: P �IONFPROPOSED WORK check all a I�cale
New House O Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: reel tCe
Alteration of existing bedroom Yes X No Adding new bedroom Yes A No
Attached Narrative 0 Renovating unfinished basement Yes _ No
Plans Attached Roll 0- Sheet 0
bar t e. ou d or ad ition�to exisTing t" using mp a =e he Il"ow n�
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?
In. Type of construction
i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes Nc
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
SECT OT( NNER UT ORIZATION TO BE COMPLETED VYNEN
OWtf S EP� CONTRACTOR�pPPL1ES FOR BUILDING PEf21V11T
as Owner of the subject property
hereby authorize to ac; or
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
re4c as Owner/.Authorized Agent
hereby declare that the statementsa4d 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.
'T��a �
Print Name IJ
of Owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
.R' 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 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:
City of Northampton
Building Department
212 Main Street
Room 100
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
1.1 Property Address: N I
k K
�AMwalpopH., of nt .
Zone OverlyyDisttict
SECTION 2'- PROPERTY'OWNERSHIP./AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pr' t) Current Mailing A , ress: 3/ S,._
k
c: >—
is
Telephon
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION-3- ESTIMATEb'CONSTRUCTION COSTS '
Item Estimated Cost (Dollars) to be Official Use'Only
completed by ermit applicant
1. Building Cr v (a) Building Permit Fee
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) Check Number
This Section For Official Use Only
Building Permit"Number: - Date Issued:
Signature:' ,
Date
Building Commissioner/Inspector of Buildings
r
BP-2004-0286
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: BUiidinQ
Category BUILDING PERMIT
Permit# BP-2004-0286
Project# JS-2004-0427
Est. Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sd ft.): 4660.92 Owner: EMERY TARA K
Zoning_URC -pglicant: EMERY TARA K
AT: 71 CHERRY ST
Applicant Address: Phone: Insurance:
71 CHERRY ST (413) 586-3145 O
NORTHAMPTON MAO 1060 ISSUED ON:9116103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 9/16/03 0:00:00 335 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo