29-516 ¢'SttiAAfP�.
O O
�} ti$ rite of Nazt4aiilptan _ r
£GT ASSAC�TTSCffB
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '>a
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNlR 108.3.4 to
act as his/her construction sup(,: , isor. 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 insaected.
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
R (riff of Norf11alliptol_l
DEPARTME1JT OF BUfLDI?','C INSPPCTIONIS -
212 Alain Strcct Municipal Building '
Northampton, Mass. 01060
WoMaIRIS C O NIEP 1 N SA S7_O N -EN S UI-,4—N CE A ITIMM)VI-I'
---
%VILb ap'nncipaJ place of business/residence at:
��'f/��l L 6 ►� � (phone:')
( d •/sta�cf�p)
do hereby certif)r, under tbc.p?-ins and penalties of pequry, --hal
(/am an employer providing the following %vorkcr's comncnsaoo, cove�2gc for Illy
etuplovees working on this job:
,419150,V �y4U1'1�s lv c�,�3/ /%��y dry OS-,O " p%
(La.Tu-n= CompaL--,) (PCUcr NLLUr_r) (T=:•pirzdbr, D=)
O I am a sole proprietor, general contractor or homeowner (c cie one) znd Lave hired
the contractors listed below who have the follo%viog workers cocoen_saaon policies:
(N amc Oi Cont: nor) (In ur-3ricc Coinpan)-/PGUc-; ?,,rudn_r;) (r`;71Tdu^ I�1IC)
(N2mc of Cona2cior) (b s -ancc CompanvfPolicy Nunn-:r) Dale)
(Name of Cotm-aci ) (Lasu nc: Compan)-RoUq- Namb-zi) (Expir000 Date)
I
(Name of Contmaor) (Insurance Comczay/Poky Number) (Ex-p radon Datc) .
(nnscb:.4 U4�.001l trca,if acoc--u V cD a�c!u�iafCCw Ca p,,6�to.11
r'
{ ) I am a sole proprietor and bave no one wor'dng for me.
( ) I am.a home owner performing all the wank, myseff.
NOTE:plea be cMjx tt,•. +1 Jo bcc,=+,m—bo crnplo),pctionr w do easr o c rgair wcr-k ao.d—a'-Z of
twt tnoc-c tb--z c -Div in ubeb Lb.bocmowvc r=do or oa the pvL a we C==-DY cn=-&-rc+d 10 t
catployca un?—the Sul rss c==pCy=Act(GLt 52-=1(5)�c.ppUaDOO by a bomco—o=far c licxx_cc pcnait try ni& —the
lc- naau of na c=ployx under drn Worlco!c Coarpam�lux
I-ad--d th+t:oopy of tbi,to=—.d m y b.ror—aj•d.d to tb.Dep.:ruama erinduu;al ne --Offi—of In-++ for Lb.
cova-xs r=Zatioa a-d U-- L-il=c to,==cov=z uodcr=c6cc 25A of hiQL 152 c.Ind to the i-=?x oo cdcriminA Pea'lli°
eoosisIu of a frac orup to 51300.00 a AVd oCup to ooc yc r e.nd ci%i1 pmshio i.tx focm of.Ssop Wori;Ord=tad t
rum O(S100.00 t d:y tplalt tnc
For dcy.rsa>•�u,c only .
permlt Ntmbcs
L Lot
Sip�Ziurt of Lia�scc/Pc - u
e J 4
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: f /�j Not Applicable 11
Name of License Holder: ,& /'V L nA bl�
' License Number
►,1 4-12
Address Expiration Date
/Ja 7,C) k)
Signature Telephone
��. �: ° x• `�" Not Applicable ❑
9 Iteaisle e'�ii�=`F'tbmet`ifil3r emerit Contractor�Y= PP
Company Name Registration Number
?. 4,orill 2
Address V Expiration Date
A Telephone-,
SECTION 10-WORKERS'COMPENSATION INSURANCE..AFFIDAVIT"(M.G1.c.-152,..§25C(6))
Workers Compensation Insurance affidavi must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildipig 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-owner-parcel_ofland 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 buildine 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 Iiable 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 ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofi
Or Doors E]
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks ([] Siding OK Other[O]
Brief Description of Proposed ^- r /I
Work: �J S !—� 1 v l yU 7� �w
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
s ` " WUN,, `RrarT� ion X1111n:g_,.cilisma c'a
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.
I. Septic Tank City Sewer Private well City water Supply
SECTION--Ta=OWNER AItT•,HORiZAT ION,, TO BE OMP4EGED�WHF�t -
OWNERS'AGENTOWC,ONTMAMR APPLIES_FOR-BUILDING PERMIT
lQ dJ Jll✓9 (-- Jy/�� as Owner of the subject
property 11
hereby authorize � W/Ai [.__
to a y behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, 6,�jLl�/ J'l� /chi fir✓ 69404w/Authorized
Agent herehy 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 <
Signature of Agent Date
'
Section 4. ZONING All Information 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
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bidg&paved
'
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Vurianue/Fmdi ng ever been issued for/on the site?
eN
NO 0 DON7KN0N YES 0
IF YES, date issue&
IF YES: Was the permit recorded at the Registry ofDeeds?
NO � )
__
IF YES: enter Book Page and/or Dooument#
�� ��
B. Does the gtacontain a brook, body nf water orvvet|ands? NO v�� DON7KNOVV �~� YES �_�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained /~�` Obtainad �~� Oate �ssuad�.
�_� �~� .
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 0 NO 0
IF YE3, describe size, type and location:
E Will the construction activity disturb grading,excavation,or filling)over 1acre or is it part ofocommon plan
that will disturb over 1acre? YEG (��} NO K��)
|F YES,then a Northampton Storm Water Management Permit from the DPW iarequired.
De a etuse=d ^A�
City of Northampton Siatt, tia 1� _ y
B011ding Department
212 Main Street
Room 100 re �` �
,.",'Northampton, MA 01060
00 rtk13-587=1240 Fax 413-587-1272 " �
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION1.-"SITE"IN FORMATION
,�' 'Thas:secfion tb be completed=6y office
1.1 Property Address: * ,
7m�iL��strrcY xC> DrstG pct".ct` 'T..
SECTION2-PROPERTY"OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: / /
ug
am rint) Currer�Wilipg Addressv P
)CTyya0— Telephone
Signature
2.2 Authorized Agent: 15P-)
� �O �
Name(Print) Current Mailing Address.
Si nature Telephone
SECTION-3-,ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building E (a)Building Permit Fee
2. Electrical (().Estimated Total Cost of
Construction;.from..6;
3. Plumbing Building Permitfee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) U 6 `.. Check Number
This Section For OfficfaCUseiOnl
Date.
Building Permit Number: Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
4% 8A.'40
26 TARA CIR BP-2007-0391
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-516 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A/
Category: BUILDING PERMIT
Permit# BP-2007-0391
Project# JS-2007-000578
Est. Cost: $4500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq. ft.): 8886.24 Owner: SCHMITH DONNA M
zoning:URA Applicant: B & R Siding
AT. 26 TARA CIR
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON.101612006 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: Date Paid: Amount:
Building 10/6/2006 0:00:00 $25.0020583
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo