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DEPARTMENT OF BUILDrI\1G INSPECTIONS /?
INSPECTOR '212 Main Street • Municipal Building
Nortluunpton,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 i ds/her construction sup,;. : 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 fanuVy-- '
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 ftulations. 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
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„� `E (riff ofl�c�rfljaill}�toli
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Q DEPARTMENT OP BUILDo\'G INSPECTICI.'S
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212 Vain Street Municipal Building
{ NorLhampton, Mnss. 01060
«'ORI-CEIZ'S COo[PENSATION MSUR -N CE AITII):i FJ-J
(li ccaS=/PCT-Mj ttcc)
a prncipal place of businessfresidence at: - — --
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2\S rb�t s� �\ �{� � O �cGG (phone:'}2A-S
(caret/city/st.aicla p)
do hereby certify, under dic.painS and penalties of perJury, :hat
( ) I am an employer providing die following ,vorkcr's cotnocnscJo;, covcm; for Ins
eroplovices working on this job:
(l.Snu-:n=Comram-) (PoLic-:Nu--a;xr) -- (T':-pir d6r, D2j)
O I am a sole proprietor, geoeral contractor or homeowner(ci cie one) and have hired
the contractors listed below wbo hive the iollo%vinQ worker's comjtnsation policies:
('Namc Oi CoP`incior) (In uranc c CoinoaSly/ll ouc"i �tUII1LCr) l�aiC)
(Name of Coalrezor) Oils-wrancz Comoaav/-Po!icv Numcrr) (-Eioir,.6on Date)
(Name of Coturdelo;) Gasura-ac Compan}'/PoUcy N:vnb�t) (Expiraoo Date)
(Name of Contractor) (Losura.n(--Comcany/PoUcy Number) (Expiration Date).
zddi'-:CCaJ t'xd,irncx�r}-w mc?udr infor».joo pcla,iai.ns to.11
(� I am a sole-proprietor and have no one woridng for me.
( ) I am.a home owner perforl=g all the work; myself-
NOTE_pl==be aw-arc tfitr`a-t }c bco eo ,n uto c=zplay pcJoa=w du ss-, cs e,aa Cr t ,t-lair worX ca s d,.c1L Z of
aot most tl:a Lb:s --tmtr is c%asiC:h the bomoawncr rude oc oa the}round's z7purte -tbec-o t--c out��.r.12y oocidercai to Lti
ei:ployes urx'„e the--mss ask--•*•cc,Act(GUI 52.n l(3)) :pprici6oa by a boa oa,,=f=e Gc==or pc=k t=y e idmcr tl:e
tc-911 cL--=of an rsployx under dt Wocitoh Co�o Act_
I uodcmn d asst a copy of ibis cut.®cn may ba foc-w—i d to tba pcQortmm of lvdutsicl Accdrnso OQi_of Ia x o-for tb<
oovc-tb-c—if—ioa AM a=t L•LM to soave`cov"-As uodc sec6oa 23A of htdL 132 tan Ie d to the i=Vositioo oft-ri.n;n,i pc=115cs
coos=3E of a fine orup to S1,500.00 atdfoc i=�an o(up to ooe yt=r tad a%i]peosltie in the form of a Slop Wort;Ordc sad s
fim o(S 100.00 t dry tatinu Mc
For dcq.rtmlJ u.c only .
P,:Tmjt Numb"
\ I\ p f1\ Y
Sirn.acurc Of Lianscc/Pcrrnittcc DaCe --
SECTION 8-CONSTRUCTION SERVICES "a
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License`Nu`�ber
Address Expiration Date
Signature Telephone
9 Re'ii e ) ofrtlifin""ra�ieeident Eai tracto'i F Not Applicable ❑
Company Name Registration um er
-----
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVi*'(M:G:L.c.15i,- 25C(d))
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....... RL 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 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
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SECTION 5-DESCRIPTION OF PROPOSED WORK•(check all applicable)
New House [J Addition ❑ Replacement Windows Alteration(s) Q Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [r-1] Decks [0 Siding[Ij ] Other[[:3]
Brief Description of Proposed `Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa I Nevin.house and ca dd�t a r to exrStinct haustnci,combtefe>fhe attbWtRi
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
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a_-OWNER AUTHORIZATION,-;'To BE COMPLETED WHEN
OWNERS AGENT OR CON TRACTOR;APPLIES FORBUILDIIlG PERMIT-
as Owner of the subject
property /
hereby authorize `� j
to act on my behalf,in all matters relative to work authorized by this building permit application.
1-6, /-/,-/ —1-1-2;2''z2 &X ) &Z&�/
SigriAture of Ow bat
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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 C ;�
Signature of Owner/Agent Date
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Section 4. ZONING All Informatibli 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
Frontage
Setbacks Front
Side L: ' R:�'' L:' ! R:
Rear I 1
Building Height --
Bldg.Square Footage % —�
Open Space Footage %
(Lot area minus bldg&paved �--
parking)
#of Parking Spaces
Fill: ' (i
(volume,&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
N0 0 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 0
IF YES: enter Book Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued: E
C. Do any signs exist on the property? YES 0 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 NO 0
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 Q , NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of NorWampton
Building Departments
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212 Main Street ewer. t< t� � � •�� �. gyp. �, .
Room 100 ��efY3F tt gatTi�rP�� iaS �r
Northampton; MA 01060 Two se sostr¢rura `E'tar�
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
Thrs section to be completed by office
1.1 Property Address:
utic����rya1 Zone Overfa Distrrct
EI[ft S 'District fC6 D�stnct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGE,NT
2.1 Owner of Record:
Nam (Print) Curie t lin A dress.,
Telephone
Sign ure
22 Authorized Agerit: f
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 °n _ (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 All
This Section For Official Use Only
:Date_,;
BuildingPermitNumber fssuedc
Signature:
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Building Commissioner/Inspector of Buildings Date
5 KINGSLEY AVE BP-2005-0575
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32C- 160 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Build'Inp DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category BUILDING PERMIT
Permit# BP-2005-0575
Project# JS-2005-0759
Est.Cost: $2900.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: KURT STAEB 127236
Lot Size(sg.ft.): 3005.64 Owner: MINTON JOSEPH E
Zoning.URC Applicant. KURT STAEB
AT. 5 KINGSLEY AVE
Applicant Address: Phone: Insurance:
2115 BAPTIST HILL RD (413) 283-6983
PALMERMA01069 ISSUED ON:1119104 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOW & SIDING ON
FRONT PORCH
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 11/9/04 0:00:00 1816 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo