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DEPARTMENT OF BUILDING INSPECTIONS �>
INSPECTOR 212 Main Street • Municipal Building '
Northunpton, 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 iris/her construction super ,,:sor. The stale 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, &L LIX 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 wor
location 3 k_ )gIm'.,
Crif�
R J f flasancllncrlla' - _
a DEPnRT1.4E1r1. OP BUIL00\0 INSPECTiolls -
212 Alain Strcct Municipal Duilding
Northampton, Macs. 01060
«VORICER'S COMTENSATION LNST_MAhCT_ AF T r1`rI7'
\kriLb a principal place of bllSlDeSsJresIdcnCc at:
i�46,xla,l/o (phone')'6 22V
(sty-t/ci tylstalcf�p)
do hereby cerufjr, under Oic.pzins and penalties of pegury; ihai
I
( ) I 1n as employer providing the following %vorkcr s comocnsZ::jon cove--Sc Cor my
employces Nvor ong on Otis job:
(Insuran= Comr. ) (Polio: Numbcr) --- (r:-pirrior, Dzir)
I -
( } I am a sole proprietor, general contractor or homeowzter (ci c;e one) and have hired
the contractors listed below who h2ve the foUoWmg worker's comoen-adon policies:
([+amc of Con=^c-,or) (It1R)t3nc; Comp0J1)'/POUq ?\Ium=r-)
(Name of Coancior) (Inure=- CompazwPo!icy Num6cr) Date)
(Name of Conlracto,) onsuranc; Company/PoUq. Number) (Expim600 Datc)
(Name of Contractor) (Ituuranc_- Compa ty/PoUcy Numbc-r) (Expirtioa Date)-
(in, z6Ai-pcc=J dcc.ifnco---. to atdu�inCoccu�oo pertninlas to.1!oo�-so:�)
{ ) I am a sole proprietor and bave no one work-iog for me.
I atn,a home owner performing all the work myself:
NOTE:pl== be awxrc th=MI_.bcc[ zo»v,-]t-b.e$picy peiQm to 6n � c=—,.=oc a rcpzz�utix on.d..<.11_Z of
oot MOM Lh=tb:rM tmia in udacb the bomomwc rzxida oc oo the pMupC;r zppur�Lbceo a.-c ox oeCxed=d to tr
erzploye s One-the�.ai ets o --,;�Am(GL!S2 a I(5)�.pplic�oo by a bomcoavcr fm a Gc�.or Parma r=7 cvr6 the
Icgs1 r==or an=:?Ioyx andc-r dro W orkce.Corapom_tioa Act
I .Ddcra,ad dxA a oopy of tbia mt=-w may b-foe—,dud to the Ocga,tmma ortoJu iJ Acodoc:LY offioo of Irsu.noe for the
oovrrx'-c unit onion and 0=1 LiIUM to s ='overase tinder=CI-ion 23A of MGM_152=1=4 to the ion of eimiaz!pcualtio
000sir=3Z of a tint ortP to S 1.500.00 ard/oc mgrtyo®e-ri of up w ooc Yc=and c%il pmatua io t5 focm or a Sum work Ord=and a
flan of S 100.00 a day tPinl3 me
For dq.rta�:-d u,c ooly
PcrmA Numb=
---�j I
kv 06 1`fa n°-- Lot
Si�,u,-tt=of crmiucc 2
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SECTIONS-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
N` Not Applicable .❑
92ernsfereomeTmproemenYDntrantar pp
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(WG.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...... ❑
ne.
The current exemption for"homeowners"was extended to include Owner-occupied DweIlings 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-vear 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 d Local Zoning ;antate of assachusetts General Laws Annotated. _.
Homeowner Signature
4k W o
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) Roofing
Or Doors 0
'Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [177 Siding(0] Other
Brief Description of Proposed /� Cr/ LA
Work: ( Ill u- f LLe- F ",4(G L 1. tz
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa t'Nernr�t oase`�a d r a diticxr�o�xtst�n tWfioiisrria comp e' o lo�ntfrig;
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,AGEN'OR CDNTRACTORAPPLIE3 FOR-A'L'D1NG PERMIT
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
LA t,..� i as Owner/Authorized
Agent hereby dec are that the statements and information on the foregoing application are true and accurate,to the es of my knowledge
and belief.
1
Signed under the pains and enalties of perjury.
Prin me
Signature of Owner/Agent Da
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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
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
�
A. Has a Special Perm ever been issued for/on the site?
NO K J DONTKNOVV YES � J
IF YES, date issued:!
IF YES: Was the permit recorded at the.Registry of Deeds?
'
NO 0 DON7KNOW YES
IF YES: enter Book Page and/or Document#'
B. Does the site contain ubrook, body of water nrwetlands? NO �~��� DONTK@OVV YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobembtmined »�� 0btainod ^-��'� Dmte |s .oumd�
�~� ' .
��
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? yED �—^ NO «T�
IF YES, describe size, type and location:
E Will the construction activity disturb(clearing,gradiexcavation,or filling)over I acre orisd part oie common plan
thawU|dismrbova,1ocre? YES K 3 NO
~
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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City of Northampton ' siPe�ity �
Building Department@
212 Main StreetQ
Room 100 b
h
Northampton, MA 01060 � ,��4
- 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'
1.1 Property Address: This�secttot to be compiefed by office
atYf t,n,t
FL-0 9EA /� ��O l0 2— 2 one Overlay Distn'ct
% t, of , 7 &.
E Distnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
W AlwwcAa, A&� )0 V
Name nt) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECT--,ION--3,-ESTIMATE D:CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ' f CJ (a)Building Permit Fee
o 0
2. Electrical (b)�Estimated,Total Cost,of
.Construction from...6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
334 ACREBROOK DR BP-2007-0200
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.-Block:29-313 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2007-0200
Protect# JS-2007-000304
Est. Cost:$15000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10018.80 Owner: SADLOWSKI CAROL&DAVE
zoning: URA Applicant: SADLOWSKI CAROL & DAVE
AT: 334 ACREBROOK DR
Applicant Address: Phone: Insurance:
334 Acrebrook Drive 586-2286
FlorenceMA01062 ISSUED ON.8/22/2006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL PELLET FURNACE
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:
Gast Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: or, 09`0114 1„vv115
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL IO
Certificate of Occu anc signature:
FeeTvve: Date Paid: Amount:
Building 8/22/2006 0:00:00 $25.004533
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo