37-065 (49) •
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DEPARTMENT OF BUILDING INSPECTIONS _ � /2
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::-.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, 1(„44,, ), ''MP 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 14/7/C 6-
Address
Address of work ) _---
location /J Pi b �,ICR jj 1 QC il / 124 / L.--
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DEPMThl Elir OP OUI(DrNG INSPECTIONS .:
' 212 Main Strcct • Municipal Budding
Northampton, Mass. 01060 r,".'
\6OPJ R•S CONITENSATION ENSURANCE Al 1'UJA\RT
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I. _11 1'i� A >J - --
oiccv.sa/pern>iucc)
with a principal place of business/residence at:
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l 73e,4U 12eif JR, J'2.o24jlC itIi4 ,G.2 (phone;.') 5k6. -3G s1
(svcs/citylswc(np)
do hereby certify, under the pains and penalties of perjury; Lh.
() I am an employer providing the following workers compcnsaoon cove.:ge for Illy
employees worUng on this job.
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(Inruranc Coor_co) (Peak:Numb r) _-_ (c:piruon Dalt)
() I am a sole proprietor, general coon-actor or homeowner(cvice one) and have hired
' the coonacors Listed below wbo have the following workers compen_sadon policies:
(Name of Coo:ncmr) (Insuranoc Colnpany/Pnucy Nunicr) (-i_pirauon Oats)
Mame of Cain:nor) (Utsurancz CompanwPotcv Numbs].) (Tiipiroon Dae)
(Name of Cooaano:) (Insurance Company/Poucy N:rmbJ) (Espiroen Dam)
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(Name of Coau2ctor) (Insuran Comcwy/Palicy Numba) (Expiruon Date)
(.4,d a:00.1 Gra Jnu a-v to ccK S:afarx.0 cc pmuaaa[to.n r_ .;l
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() I am a sole proprietor and have no cue woridng for me.
(7a I am a home owner performing all the work myself.
NOTE:plmssi c•-_rc u:wt.-pc becccomacn uto ploy pavocu u do .-,+ m
work on.d..otko;of
op(myet= aw.a!(uuvydtbcb .cam or
I(5)). nomads _a Vr fa oxo-Jl.ae ye,doc
=splay=undo.,We wefc:cq=ym Aeoocoptaiott aaptenw H.E�^m rQ:Go-«t..,..�.�_r";am=LM
1�e..uu of a�lcr.r=St a>a w .c�.a;oo nx
l uedc¢._,G tho.m%a(y.mam-m m.r b.(u+...Ld ta ts.11r,. n orl.dauiu Acadc Oso-e1leu.nm for W.
m`cl vciGeli°a vd thn Lilmc to tosstonic- ^.4"}Cama 15A a(MOL 151 con led b W- co ofn a4 pcnshi
senwai8a(.6«orup b SIJWM uWar�vacammo(up toone ttd i1v is rote. r., 'cad
Sop wmkoodc.d.
of 3100.00 L.day.pim mc.
ro.ha.nm�y u:mr
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l" (c1 6`J/yL'^ tiV _ 4 J`7 hUP _N_mr Lot: ..
Signature of Lido- cnniucc ,tAr� . .J
! of Northampton Status of Permit: Department use only
Vi V , tling Department Curb Cut/Driveway Permit
r, �� / ,Main Street - Sewer/Septic Availability
- ' r" oom 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 418;47-1240 Fax 413-587-1272 Plotrsite Plans
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°�i '0 Other Specify
APPUCA'TION it CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION t-SITE INFORMATION
1,1 PtooertvAdtlres-rte This section to be completed by office
/2/Bi-ACx t3i�2(L/'IINT24il. Map_ Lot Unit
/-(n( ,UCL, A"l A- o1 a6''-- Zone overlay District
Elm St.District CS District
SECTION 2-PROPERTY OWNERSHIP!AUTHORIZED AGENT
¢,I Owner of Record: -,HP-Si/4 164 )QF/3MA,J /-2-473i-ACK )712eN TPA l<_
Name( ng 1 Current Mailing Address:
LL� ��y Ifs e `hoe Flc-sCS4
Signature
2,2 Authorized Agent:
Name(Prep) Current Mailing Address: `—
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1, Building 41/ 000 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of It
Construction from(6)
(1000 . UCS
3. Plumbing Building Permit Fee `{-.
4, Mechanical(HVAC)
5.Fire Protection
1
STotal={1 t2+3t4*51 #x,00 C} Check Number .o1lt 15 Q
This Section For Official Use Only
Date
Building Permit Number:
Issued:
Signature: —..... —. _
Building Commissioner/Inspector or Headings Date
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Witt-, Do Sft€ V($ ( T To ASSESS sttof to.0
Section 4. ZONING Alt Information Must Be Completed.Permit Can Be Denied Due Ta Incomplete Information
Extsi,� Proposed Required by Zoning
'Thrtficrof do CILV Ilea column to Bo filled in by
ff.]" Ci AG'.40,cS/„�' Building Dwartmont
Lot Size M+-'
Frontage
Setbacks Front
Side L: R: T.: R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage m/e
(Lot area minus bldg a paved
Moiling)
N of Parkin S,+a+s
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding� yever been issued for/on the site?
Y7
NO 0 DONT KNOW � YES 0
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW { YES 0
IF YES: enter Book Page and/or Document=
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O 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 O NO 0"
IF YES, describe size, type and Location:
E. Vel!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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House I J Addition ❑ Replacement Windows Alterationfs0 Roofing J
Or Doors 17/
Accessory Bldg. ❑ Demolition D New Signs [01 Decks [q Siding(n] Otter[Cl
Brief Description,of Proposed •in'
Wort atPtf✓.1E i-2st7=- 1 fr/ -.n ubc3AL(S4 A/.0/SF/ pXII 2020H Gc, (2/Q436-` -1 1M
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement �( Yes _No
Plans Attached Roll -Sheet • `
ea.If New house and or addition to existing housing, complete the following:
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a. Use of building:One Family Xt 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
0. Number of stories? ._....
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 AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i. as Owner of the subject
PIOPery
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit applicetion.
Sgnatinre of Owner Date
MAt-fig- ,as Darner/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,
P(.14M 4 }J tt[p3
PO:1gal
Signature of Owner/Agent e
SECTION 8-CONSTRUCTION SERVICES
8,1 Lloensed Construction Supervisor. Not Applicable 0
Name of License Holder:
.—_ License Number .—.....
Address .�. Expiration Date
Signature Telephone
S.ReWstered Home Improvement Contractor. Not Applicable ❑
CompBnv Name Registration Number
Address Expiration Date
L _Telephone_
SECTION 10-WORKERS'COMPENSATION 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 Cl No ❑
11. - Home Owner Exemption
The anon exemption for-homeowners"was extended to include Owner-occupied Dwolhnfs of one(1) or two(2)families
and to allow such homeowner to engage an individual for him who does not possess a license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 1083.5.1.
Defmitian 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 duelling,attached or detached structures accessory to such use and/or farm
structures.A person who constructs more than one home in a two-near period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official that I e/sbe shall bg
responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on the job site will be reguhed 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,von may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned-homeowner"certifies and aevvnes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State anc Local Zo Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature f .y l(A✓(r_. -c.3