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DEPARTMENT OF BUILDD�,TG, INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northwnpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNM 1083.4 to
act as 1-is/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 rouzh building inspection (before work is
concealed), insulation inspection (if required) and a fnal 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
R E (riff Ofl�t�rf11a111}�fot� -
DEP:IRTME?,T OF BUILDP�c INSPECTIJONS -
212 Main Strect Municipal Building 5.
Northampton, Mass. 01060
WOEUCER'S CONOENS/1TION MSUT-LNCE AF MAVIT
L,
(1i cc-as�Jpermi tied)
%VILh a pnncipaa place of business/residence all
/( kin) Grr+ss A,*// Xi! &44k A* &&iqX (phone:') 4//3- F-/Gl
(sa-�c/ci IsulcJrip)
do hereby certify, under Lbe.pa-ins azd penalties of peflury, .hal
( ) I am an employer providing the following %vorkcr's colnpcnsZLion cove^ge for my
emplovees worlong on tills job:
(Ir_s== ConrLcy) (Polio: )"'umb-cr) --- (t ,pirroor, Dzie)
( ) I am a sole proprietor, general conrsacaor or homeowner (ci cie one) and Lave hired
the consa(nors liste-d below rybo hzve the fobo ' p worker's comDtnsai7on policies:
(ngnoc ofCon,rMctor) (Insutan Cornoan�yPcuc; ?�tumcc:; �ti7ii-aeoc Date)
-- (N—c of Cono-mor) (Ins-urancc. Companti•iPoUcv \uocrr) (-EkD -,don Date)
(N.me of COnII,C-16T) Clas ranczz CompaDy Polk}- Numbzr) (E\pimrioo Dalc)
' I
(Name of Cooa-aelor) (Losuranc-- Company/Policy Number) (Expirdoa Darr).
(dnacb_ddit CC=l d Cf tf nG,_V to Cz C!udv in.form,.=j oo pcstn; to.11 doer-r-..o:-s) 1
C,
((�I am a sole proprietor and have no one wori;3ng for me.
( ) I am.a home owner performing all the work myself.
NOTE:pl=s be nwuc q,,kI:Dc bander cn wbo cmplay pcs.oat w do cx c�-..:c.,ao c mzzu••roci on.d��c1L•=�of
nod tnoct ih::n tl`ioo-tmr-J in ulneb the bamoownc raid.=o<oc the p-ouo6 appun<a�=the e..n ox G._rr,Uy oc=.d.-cd to be
eitpioye-s und=the .uid Oz:�eo Act(GL152y l(5)�rppliapao by n boa=--=fw a Gem=or permi r>_y e'46=oc t1 c
lcg wu of a ex?loyer uoder dw Wo&cez C tioa AZL
I uodcn.and th.c x ooyy of tail —y be fo—nrded w tbo ticpo.nmcot of Induriicl/,_d_&OQioo of 4a-a.r.nco for the
covarx�;c v=jBc=Iioo and Ih_t C=Jm-c to sccL=,covcrasc tn]d=suction 25A of h(oL 152=Icd to the icrwsitioa of cimiazl pcueltia
ooa.ixiag of a fine of up to S 1.500.00 andyor a=a-iyoomc=of up to one year tad o%il pco j-ja in tk form of a Stop Work Ord=and a
fim of S 100.00 t d_y grins.CDx
For der• -r,t v.c only .
I ) Pcrmtt t�It>.mt>cr
Si tint of Li crmittcc e
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9 NRed 9sf'ered�7loriie ImprawerraentCantractoi - z � Not Applicable ❑
>lI�INtiG its S/�I Ahs�'� /?7fS
Company Namel Registration Number
'0 err ass AJJ141 / oil 0 93 Tajo-�.2do7
Address ol r f Expiration Date
Telephone 1/Ne0t P1G/
SECTION 10-WORKERS'COMPENSATION'INSURANCE.AFFIDAYLT(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 buildi g permit.
Signed Affidavit Attached Yes....... No...... ❑
The current exemption for"homeowners"was extended to include Owner-Qmyied 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.
Defir ition-of-Homeowner-:Person(s)-who-o_vn-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 D
Accessory Bldg. ❑ Demolition ❑ New Signs [oj Decks [0 Siding[0] Other[p]
Brief Description of Proposed
r► AW F',t .e-<f,`Work: J��CS1P1t �L
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ctl+'�':
sa 1' N�ev� hoasea d aadtiofa ezistliict houstnompee#iatav�ic�:
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
L 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
SECTI.ON'7ar=OWNEi2 AUTHORIZATION .=T-0—=BE--'COMP—LET 1AIHEN
O.WNERS:AGENT .ORICONTRACTOR-APPLIES FOR;$UILDING PERMIT
ar-a Qx"s as Owner of the subject
property T
hereby authorize / ary— 'Su man56
to act on my behalf, in all matters relative to wor uthorized by this building permit application.
Signature of Owner Date
J to Owner uthorized
Agent hereby declare that the atements and information on the foregoing application are true and accurate,to the of my knowledge
and belief.
Signed underthe pains and penalties of perjury.
Print Name
it
-ob
�1- ag
Signature of Owner/Agent Date
'
'
^
Section 4. ZONING Ali 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 bldg&paved
#of Parking S aces
(volume&Location)
A. Has a Special Perm it/Varanne/Fimdi ever been issued~for/nn the site?
�� ��
NO \,��� D0N7K0OVV �_� YES \~�
IF YES, date issued:,
IF YES: Was the permit recorded ot the Registry ofDaeds?
08 �� D
\�� v'v ' ^,"vw' 0 YES
IF YES: enter Book Page; and/or Dunument�(
��
B. Does the site contain a brook, body of water orwetlands? NO \�_��� DON'T KNOW \_� YES ^~�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tnbeohtainmd v�� Obto�nad �~� Date Issued:
�_/ \�� ' '
C. Dn any signs exist on the pnopert �~� /~�^y? YES \~� NO �_/
IF YES, describe size, typo and location: |
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,nrfi||ing)over 1 acre nrioit part ofa common plan
that will disturb over 1acre? YES � ��� NO [ l
|F YES,then a Northampton Storm Water Management Permit from the DPW is required.
`
Department use only
City of Northampton
€ _ "
P
Building Department
artment �" a ry
212 Main Street SeIS'' ab7it
Room 100 tl� e �1�ra abet �` a
Northampton, MA 01060 �
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: l9C./C�AOAdC This section to tae co[nplefed bX office
it -
Zone O�e>rlayHDEStrrct
Y�
M +•
� YL
Cdr<x��t.D�stnct ;�. .�` C6."Dis�rct
SECTION',2-r PROPERTYOWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: ^
�Se a e_r-/ti lkq&ra r}J t�► /yam,St /y�l�Ft/d
Name(Prin) Current Mailing Address-
Tele'i hone
Signature
2.2 Authorized Agent:
N me(Print) Current Mailing Address:
r'
.-SiciKaluke Telephone
SECTION.3-:E$TIMATED:CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b permit-applicant --_
1. Building (a)Building Permit Fee
2. Electrical (b)Estimate6 Total Cost of
Constructiom m 6)'.
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6_ Total=(1 +2+3+4+5) Check-Number
This.'Section For Official Use=Onl
Building;Permit Number Date
r.
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
12 HOCKANUM RD BP-2007-0605
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32C- 192 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2007-0605
Project# JS-2007-000891
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: M & S CONTRACTING 139298
Lot Size(sq. ft.): 5009.40 Owner: LAPERLE JOSEPH E&MARY POWERS
Zoning:URC Applicant: M & S CONTRACTING
AT. 12 HOCKANUM RD
Applicant Address: Phone: Insurance:
11 GRASS HILL RD (413) 665-8161
WHATELYMA01093 ISSUED ON:1112912006 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 11/29/2006 0:00:00 $25.00112
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo