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(''.'i t--� DEPARTMENT OF BUILDING INSPECTIONS ', = ` /=
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060
r
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
, J OO/`4/f if,, } ' ,,1 understand the above.•:ome owner/rest.ent s si: ature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date l��,/4, `►/
f
Address of work
location
•
0..A.).4 •
Oc-
of Nartliampfuni
• k
Ei 474.,tab,f
41 CAI 51. T-Wi
t„ 41747 =
' • ;2:4.):,'
DEPARTMENT OF BUILDI7,ZG INSPEc i IONS •=---„,_7,-,-11
212 Main Street • Municipal Building
Northampton, Mass. 01060 ‘4•
WORKER'S COMTENSATION INSURANCE AFFIDAVIT
— _
(liccri.s..z.ciportnittcei)
with a principal place of business/residence at:
(plione )
---------
(StretiCty,1: 111.•:-/zip)
do hereby certify, unc or the pains and penalties or perjury, that,
( ) I 2._ni an employer- providing the follov.-Ini: worker's compensation coverage For my
employees working on this job:
- (Lasuranr--t Company) (T)oliCy Number) (E.):pimtic_•n Date)
I ant a sole pronnetor, goner-c conor arhomeomer (ch-cle one) and have hired
the contractors listed below'cvlio _ cvmg workers conlbens,ataon poLrctes:
iiA ,
(Name of Contractor) (Insurance Contoaay/Polie-T' l'hirritcr) (1_::...p:ratacr: Date)
(Name of Contractor) (Iurrmcc Com:Datay/Pohoy Number) (Exciration Date)
(Name of Contractor) (Ins-urancz Co ai pan yiP o I icy Number) (Ex;-;:ratioo Date)
(-Name of Contractor) (Insurance_ Colllo-anyiPolicy Number) "Tai..,:riration Date)
( !Lath octal ,i; '
) un a solo proprietor and have no one workyric; for me.
( ) I aril a borne owner p(:.;:":071'.111"1`:, all
NOTE: )!cc (Ea: "0-7:7:-=-=-1• e.) ,or -c-CItLC
not anoce th_to thrtio tu in wOch 1.1x razi,:zz oc, arc(7:{CL—Krally
czCptoyu- woa.kal'a 52,:e 1(5)),r.c.7,11:a:ioo oy a h0;:1:-.0,vDc1 for a th-a
I agal rtatua of r.n can:ploy«und..«tho Worica-es Conapor.,....s.tion Act
I un..d.c.-stxncl tile a copy of alas at.tc,...,711 a-Lay bo to tar,1),:po/1...-nc.na of Indalstrial Ac.0 Oflioo of .ccccrro for lirc
COVCrtgc vcriG .,tiocl and that fe_ilurc to:,:clue :cctioc-25A of 152 can lc.u.1 to the impositickn of
coctliztg of a fint of up to si000.cv3 of op to cr.-. ar.i civil pcnt/tIci In tic fcx-in of. 5tc Wcria Oicu r,...1 a
firx of S100_00
_-----
For UoC only
• Parnit Nainks _ _
--' t/nr.,4'
:igun tirc cit I,i.cc:1!-,41 _Nu ittcf.:.
A
SECTION 8 .CONSTRUCTION SERVICES,
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
' Re ere,' brie ;me ®semen.«:Con racto T 7�R5__,. 1" Not Applicable ❑
Company Name Registration Number
Address Expiration Date
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 ❑ No ❑
"''''s -,-..Z:?,2. :o.-t lie,,::.. .--,n--..,4a4,;.,;;.%,-.7:::„47,:kr ..
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.
\A .
omeowner Signature 1` ',,,/,/�/'� % 4n •ii.d
i
SECTIONS DESCRIPTIONsORPROPOSED WORK check'all a•.livable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding Other [ ]
of Description of Proposed Work: V4/A/714 fLq"/41
Alteration of existing bedroom Yes r No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
sa ifff_ a houses nd or d.d"d:itionw,t rd.ki.stih housinQ,:d6Ni Et fheff.nlo ifit:
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
SECT10 Wi-4 R AUTHORIZATION -TO'BECOMPL"EYED;WHEN
OWNERS!A`GENTot'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 building permit application.
Signature of Owner Date
I, , as Owner/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.
Print Name
Sign; re of owner/Agent Date ///4//3/Ja 4l
4 •
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 V
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 s/ 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:
A L
�
'� V ;
� � „a _City of Northampton _ u 1ei'- Building Department x -:--, a ' �—
—7- _I 212 Main Street a s 1 V, i . �1 Room 100`_ 14 hampton, MA 01103 650 87- :ro ° '� t,1!! l ;Iibne - 87-1240 Fax 4 1272 �-7 7,g,. r „ 4 .„ w- 4 -
flit' .tiS
APPLICATtC-ICI ,(I:ON CT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
This section to be completed by office
1.1 Property Address: � _ a � � y
f r d "u :k ±.
7h fG "., Map� � � 11.0 `�i "��j g w Elnrt
J P��f �� /,/,f7 Zone Overlay District
(� 17
Elm St.District CB Distnct :
SECTION.2-PROPERTY AGENT
2.1 Owner of Record:
/.44M,q f' _51 fM i •4'/
Name(Print) Current Mailing Address:
HEFFEI. d4,,/ Jr4K T G�ipf n;, ,d j ,i
Telephone
Signature74", _& "O/
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 permit applicant
„� Building 'gdd (a) Building Permit Fee
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 3 Jr-
This Section For Official Use Only
Building Permit Number:. Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
1
4 HEFFERNAN ST BP-2004-1275
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 11C-005 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A)
Category:vinyl siding BUILDING PERMIT
Permit# BP-2004-1275
Project# JS-2004-1489
Est. Cost: $5800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 17772.48 Owner: STANLEY THOMAS E&LINDA A
Zoning:URA Applicant: STANLEY THOMAS E & LINDA A
AT: 4 HEFFERNAN ST
Applicant Address: Phone: Insurance:
4 HEFFERNAN ST
LEEDSMA01053 ISSUED ON:6/14/04 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:
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 6/14/04 0:00:00 4932 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo