29-514 (6) O4St1A1`tP�� � •
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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 780CMR 108.3.4 to
act as i:is/her construction sup,,, .i sqr. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or"two fami�
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
T
Address of work
location i7 7�,
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y
WNW
F E (riff of
Af $7 ca a a Chntctla' _
r DEPARTMENT OP BUILDrNG INSPPCTioll'S - —
j 212 ?`lain Street Municipnt Building
Northampton, Mass- 01060
I
WOIUG:R'S CON ENSATION MSUR -NCI- Arl=AAM'
I '
I
�' (liccvsxJperm)ttcc) - -. ._.._.---
,VILh a prLZcipal place of businessfresidencc at: —
(phone--)
(sus/citylsZzLdz/ p)
do hereby cerdfy, under O)c pains and penalties of per' , hai
j ( ) I am an employer providing the followlD-,'worker's comocns-n:ion coverasc for lny
ea3plovecs Nvorldng on Oils job:
jasl=an=Coapanv) (POtiC(Nt-Mb-Cr) -- (r',-piration Date)
( ) I am a sole proprietor, geoeral contracor or homeowner (ci:c;e- one) and have hired
the contractors listed below vqho hzve the following worker's cot 7easadon porkies:
(N qM,- o1 Contmaor) (Ina-'r3nc-c Coinoan)•/PoUc"i N't1 h--7) (-IX:)
I
I
y
(Nzmc of Coatnaor) Ons-Wanec. Comoanv/Poum, \umccr) (LxDuw lion Date)
(Name of Coauaaor) (Insurance Company/PoUcy Namber) (Expirz6oa Daic)
j
(Name of Conlydelor) (Insurance Comra.ay/Policy Numbir) (Et�in600 Date)-
(aaaCzb--d:iiiocsj rxa.ifacc,csi_-y to it ?u�dc iarorcv=ioa pc-tniaiag to.0
{ ) I am a sole- proprietor and have no one working for me.
1
( am.a home o-,vaer performing all the work myself.
NOTE:pi—be ew uc t*z v f Ic bemcowvcra bo cmplay p-Lcr=to cU ar ncpair W oric on c d—U--ma of
Mot moct —,,J is Xb, the bomoowvc mmd.a ea the V-v�z,�purten:a tbecn�c we C-=ny W=-d.=d io be
eixploycs uEI('-e the-u-k&z C=MP -^•on?a(GO).52a 1(5)x,=pplinboo by a bomu*ova fc-6c=.cc{xnnil trey e idmcc the
Iesal ctaaac of as espioy-aodor d.Wock.olc Coo3poon.tioa Act
[uaderttiad that a oopy of thu eatzmma may be foe-r.urded to Lb.Dcpertmcvi of Induxrid Ac Via'OfG-or l+a++r•oce for the
Ili Oovcra;;c v=4LC=ioo sad Uu L:.iltac to sccauc tovcrybt aide uxiioa 25A of MOL 152 na led to the L=p=itioo of ciminal peailrio
ooaiu.iag of a rune orup to si�oo.00 andlor tai of up to ooc y=and avtl pavtUa to iSc form ora Stop work Ordc nad a
F1=oC S 1 00.00.d_y.Pjast me
Forte u.c only -
permit Numb= —
Lot
` sirnacurc of Lio=lsr�/Pcnniucc Date -- J
�t
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
9:�Reaiste�e"� 'ome:lmprovemen�=�ontrac�n � �'
Company Name Registration Num er
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE.A1 ,jD V1T:(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...... ❑
n�r����eanp�=on
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
.....
SECTION 5-DESCRIPTION OF PROPOSED'WORK(check-all applicable)
New House [] Addition Replacement Windows Alteration(s) Roofing
Or Doors EJ
Accessory Bldg. ❑ Demolition ❑ New Signs [r]] Decks (0 Siding[0] Other[0]
Brief Descr ption of Proposed }
Work: V2111,
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes ✓ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
r6 'i'+'-4". mg^C.- ' .,.:"A�"Y�` ,,. `k..,.�..,,7•.� ,.. --�"„ 1 "�S'.,,.rr �..°��"""';��,.� Fx"�^r" t
sa-'i `New`hause�and�-+or.' �"dig liog�to.`ezts#i>~ct_kaous�ng.r comp�ete:ttieo110wrng:
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 7a-OWNER AUTHORIZATION-TO;BE COMPLETED WHEN,
OWNERS,AGENT.OR CONTRACTOR;APPLIES FOR'BUILDING.PERMIT-
7ti-<�-� �ril�c 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.
Si ure of fine Date
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
Signature of Owner/Agent Date
r �
Section 4. ZONING All Informatioh 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 l
Frontage I
Setbacks Front I
Side L:{ R: L:� ` R t
Rear
Building Height
Bldg. Square Footage o —1
j
Open Space Footage %
(Lot area minus bldg&paved + F-7
parking)
#of Parking Spaces
Fill:
volume,&Location) '
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 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 YES 0
IF YES: enter Book t` Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
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 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
0 .
r NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
petaait e I
Re
City of NortPampton
Building Department z�
treet
L� TyQO � e
6 1°
Northam n 'MA 01060 TWO s it r s y
- phone 413,-5a7-12 ax 413-587-1272 �t t ns
FEB - 7QS
4
A PLIC TION TO_,CQItLSTRUCT TER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION RM�
This section to be completed by office
1.1 Property Address:
h
' 7 1 ni GK'J< 1VIap� Unit
(a rj k v�c z (1✓1 Zone OverlayDistrict
U � 0 `"``� •Elm St District :GB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
c�-I.��r t'lo✓e��cc, of L
Name(Print) Current Mailing Address:
r x-41;...1j`q -7
Telephone
Signature
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 ermit applicant
1. Building 0 (a)BuildingPermit Fee
2. Electrical it (b)Estimated Total Cost of
-70 Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(I +2+3+4+5)
Check Number v d
This Section!For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
•
File#BP-2005-0766
APPLICANT/CONTACT PERSON BRISSON STUART J&
ADDRESS/PHONE 25 TARA CIR FLORENCE
PROPERTY LOCATION 27 TARA CIR
MAP 29 PARCEL 514 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: FRAME&INSULATE BASEMENT WALLS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9101ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street C ssion
Lod
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
27 TARA CIR BP-2005-0766
CIS#: COMMONWEALTH OF MASSACHUSETTS
Mal2:Block:29-514 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0766
Project# IS-2005-1073
Est. Cost: $1270.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use crow: Homeowner as Contractor
Lot Size(sg. ft.): 14723.28 Owner: BRISSON STUART J&
7.o4ing:URA Applicant: BRISSON STUART J &
AT: 27 TARA CIR
Applicant Address: Phone: Insurance:
25 TARA CIR
FLORENCEMA01062 ISSUED ON:2110105 0:00:00
TO PERFORM THE FOLLOWING WORK.-FRAME & INSULATE BASEMENT WALLS
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-4 I gi U r/ Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI N OF
ANY OF ITS RULES AND REGULATIONS,
Certificate of OccuNancy si nature:
FeeType: Date Paid: Amount:
Building 2/10/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo