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DEPARTMENT OF BUILDING INSPECTIONS '� _ 4 /,
INSPECTOR 212 Main Street • Municipal Building ' W .
Northampton, MA 01060 .
i'
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 Hsor. 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
o f p"y >,t�
CL lf1J of \ Lull t�ll f L1ll
J~{ 11 �!j6 ,fYlaSaricEi 55th
•
I t'PAR"IOJENT OF PUII_DOIsZG INSPECTIONS _
212 Mnii1 Street Municipal I3uilclini; �\
Northampton, Mass. 01060
\VORKEIZ.'S COMPENSATION TNSURANCF, AFFIDAVIT
I at-- Cr SST
(lic�� cJr�� mttcc)
with a principal plact' at bus noio /rcoiciollCe a t.
p ( c c_tc s l � - . - S 111,1 tie
stir vein? < p)
(10 hefeb cc.r of perjuIV tht -tt
I am 'Jul cIIlplo)'(:i c n\ c . o {
employees yS'Olk:MP 1)11 i'11S H;l`
(IaSomanc Company) (Yotic- Number) 1.)010)
) I :_I' i1 a sole prODilctoi, oi horrieowncr ccllcic 0I10)','_IlC l: "ove ;1rCU
i
the contractors listed boioa ','n. Ilaan He toilot,'v.aC woFklc; cOIP :aenaattloll
(Name of Contracic1) It _,tu,.:1e Ocinaa :r „Folic; Numt_;! Uat0)
(Nalllc of (_oi.t :2cl o: ;
(Name of Coat_oont;) lil,�[inl :C (Uliij .,}'(1'01 �J N;:n - r( . '.
(T acne o f Coona tot) Dina :iat:c x _ , },1�O1 1111117e :')
(alt.acll .. Y ,_ � [.11
',1117 tI Sole VI ()pi 101 'CO 11aV■; 110 1)110 .. U: lilt tot 1110
(, ) I ',1111',1 111)1,10 (`\ �. P :till
- IT_ pfc-_,, L_ evVU' (I tt t' • ' t,._. :. >_ � „ ,r� c .i 1 1 lr c ._. :. c cxn�c, ,i. : ; : -..L
not utccc limo thrcc t:,v±t i : circa :n l _ . rC t C. <x, ' 1 . i ae vr.cr r t t`xsCc r ) . _ < pct-r , r•
caip10}t3 un'cr the: „ r:1_ a- ,. . ac . i (61 ,1 ( Sl ; l - -i ._i_ .,ry r 1-,01ncot -r1 for
Icgai vatuz of en cauployo-r under tOo WO, o'. Co :rlmr..ti t Ad_
I undc;ztxnd that a copy of th . c t coy bo (urt o od to tic lUportn .11 of Intut.rt.J Atoy,antt O!Irto of for ll,
coverage vr; ification n.ui chit failure to t -:cost co 100 urOcs 25A of MGI, 152 can (cad to tht i :np001(00 ofc uniC_I IVrCOI :.es
ooaiuting of a firr_ of up to S I,!,00 00 n:`:'(lr ....,,ri :x:11t. -:u of up to c:r }cu n:.j civil x zutlia r7,t of n St St ' , Ati'ct }... ti.,
fir of 7S100.0{) a city 1(tOO.t (n-_
I ck ;;,ants =1.1 uK ,:t,I
Permit 1`htnitx
6 /Ve l' - :
, ltnaturc of
•
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
� :�- v ".«.�z�.�.> � :' �. ,, a+� .:;f � ti_ ue°, t�5`�`,� 'fie '� €it^" �,ti a r � .,
,9.IRritered.TAI Impro em"entCo ;� t ,�,,,,� ,� _, �� , fl Not Applicable ❑
(i J CO cv .-- _ /0 Yoo
Company Name Registration Number
s 6 pit o - 4 1 z //o/a �f Address Expiration Date
Y 5 J41i9 Telephone fSI4. X7/%1-
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 ❑ No ❑
'!..1 onteM,Wilier Wei II pain
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 fe- 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
SECTION " 5 DESCRIPTION=OF PROPOSED WORK (check all applicable)
New House El Addition ❑ Replacement Windows Alteration(s) ❑ Roofing El
Or Doors )-
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: i L o' g- Wit
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet ❑
6a. If ?NeW housea.and'.or.`additionto "'existing °housing, cornplete" " "Ahe"folIoviing:
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
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 property
hereby authorize _ to act on
my behalf, in all matters relative to work authorized by this bu permit application
Signature of Owner Date
I,
c1/1 iti Iry _ l _ , as Owner Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to eZerst
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
,4 ‘/s
Signature of OwnA -gentt , Date
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 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:
•
•
• r. of Northampton St us o 7 Pet
� _
"b D epar t ment
212 Main Street Sewer�ISepElc f �' ®� '"
JUN - 4 2003 i Room 100 Wa e IWetl a
Northampton, MA 01060 TwoSets .. 91 5trura'a;
� p,hone_413 -587 -1240 Fax 413- 587 -1272 Plot %SitePlans
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be- completed by office
7 , / I , 5 r Map Lot Unit
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) Co rent Mailing Address:
_,$ -7 1
Telephone
Signature
2.2 Authorized Agent:
_ ' vVt1 w'_S t — S ✓IAOC,C� -5! — l- - 1 0 11 1-- O /O _S
Name (Pi int) Current Mai!Ing Address:
j_ �►, 6 k
- ignature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS 1
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1 Building (a) Building Permit Fee
„ ..s s . (b` _timated Total Cost of
Construction from (6)_
3. Plumbing Building Permit Fee
i d_ Nlech pica (HVAC) I
5. Fire Protection
6. 1 otal = (1 -+ 2 + 3 + 4 + 5) if �.� , Check Lumber / 5
This Section For Official Use Only
P Building Permit Number: "Z� Date Issued:
Signature: _ / e
Date
Building Co! issioner /I spec or of Buildings
87 i:i'' BP- 2003 -1114
GIS #: COMMONWEALTH OF MASSACHUSETTS
- ,.;_.:;,,4nitettni 4 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: windows replaced BUILDING PERMIT
Permit # BP- 2003 -1114
Project # JS- 2003 -0465
Est. Cost: $1453.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett
Lot Size(sq. ft.): 7361.64 Owner: PEREZMONTALVO JAMIE
Zoning: URA Applicant: John Corbett
AT: 7 STOWELL ST
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586 -8712
LEEDSMA01053 ISSUED ON:6/6/03 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 3 DOUBLE HUNG AND ONE DEADLITE
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 6/6/03 0:00:00 1587 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo