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DEPARTMENT OF BUILDING INSPECTIONS
Q
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/leer construction supc:,,, sor. The sta±e defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two family
dfvelling, 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 baekfill),
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 7
understand the above.
Jlom ier/resident's signature requesting exemption)
I will calt to schedule all required building inspections necessary for the building permit
issued to me.
Date'` -„7�''(�3
Address of work
location c,��,17
J'T0
-
&` Criu >�f 'Ltz#1?�t�lt}rfnll --
B - 6 1+�tSIIAChItSC11II ' — —� i
—
'p DEPARTMENT oP PUILDP?G INSPEC'NONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORICER'S COM-PENSATION INSURANCE. AFFIDAVIT
(]ink J�r;:I:ituc)
with a principal place of bushmsdresidence at
do hereby certlly, undw the pains and penalt!es of po.rl my, thin -
O I am au employer providing the WHomn; warWs compensation covera�e for :ny
employees work-ing on this job:
(TIlSllr 01 Company) -- --- (l ci:�:Nu:nbcr) ---------- (E pir,:tfon Datc)
O I ant a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who Have the follomp workers compensawn policies:
(Name of Contractor) OIISIII IIC Nmnt--r) Date)
(I�'ame of Contr<:cior) --- (7nsur�nce Coin!. �/Pe!ic� Num�r) t Giratioa Date)
(Name of Contractor) (Insurarlc� Comi;2npiPolic} Nulntxl) �;I=.x4::r,:non Date)
(Name of Conti-actor) JaSU>anC-Z Courr,: }'/Policy Numb^r) (Exairaion Date)
ttae3l ad!i:ioe:al c!xd iPr.cre:v^::n i��!•.:cts i��ortru:i� r:::a:ninr,'..�e!:
( ) I <u11 a sole proprietor alld have no one 'v,.-c;_kmg for rile.
I a IIl a holne ON"'n'e: pCr)CrI11n all t?] v"(::..'-
No•rF:plc.-ac be ill �h`.:ilc h<xa szrr� :r�c;;pl >;:.
oy i 4o? •:,::-.lcunc,,
r_ot ttlOCC than thrra units in��i::c't Ltr k�;.a�c«i:cr res:�-�cc a�th.-�-.•;,'�:ar<:rtcr,rS th�cto c:c t�t�crrraly ccc.i::c::':o h
cZnloyca uavr the cvor} ', x xx;ati n Ac (6L1 S2ya 1(S)},r r,!:c_�o:by n hotncow r for a Gcerr c<p_ra:::rm:c.i_ kc Lx
Icgal ctatua of an omployor undtr tLa wor{ccez l x xrizatioct A X
I understand that>copy of t}u etat,--a nvy bo fot—mrdod to tbo Uctxut—.,f of Indiistrid An66c ff OfGoo of I:�v�=a for t1m
covcrngc vrrifiicatioa raid that failure to aca=covctnbvtu:dcr cQ c 25A of MOL 152 can Icad to tlw iniposition of mmiril pa,alt;cS
cvmistmg of a On of up to S1,500.00 a:t1'or 01 11")to err} r yj civil penalties in dK fcmn of n Stq)We i O i and a
frbo()(:S I OO.w a day tl;r-in_,t ny-.
n
Fm&T
-mm,U——ty
-----
,fi 77f7 --
_tc�.t.,cJPcrnl,t c� -
SEC TION"8CO,NSTRtJCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
�� '. ��* �. Not Applicable ❑
�Regiteredt°ome"mprQvem`ent='Contractor R �.Ew PP
Company Name Registration Number
Address Expiration Date
Telephone
SECTION l0 ;WORKERS' COMPENSATION INSURANCE AFFIDAVIT(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...... ❑
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 as mes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, Stat nd Local Z ling Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
i
i
i
.. s
SECTION 5 k'OMCRIPTION OFO PROPOSED WORK check all apalicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [I] Siding[ ] Other [ ]
Brief Description of Proposed Work: Ug c 1C
Alteration of existing bedroom Yes_X No Adding new bedroom Yes _ No
Attached Narrative 0 Renovating unfinished basement -Yes No
Plans Attached Roll 0 - Sheet 0
sa 1f New hotase�and o -diti6i to ezistii g:Housinl? tc l'etee ti"-1 11owinJ!;
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. Mascheck 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 7aiOWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT,OR GONTRAC°T.ORAPPLIESFOR BUILDING PERMIT
3
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
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.
72
Print Name --
Date
i6ature of U ner/Age
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
l Building Department
Lot Size / / L7)
Frontage
Setbacks Front S;?_ 40/
k Side L:Awl R: ' L: R:
16-
Rear
22—,
Building Height
Bldg. Square Footage O %
Open Space Footage %
(Lot area minus bldg&paved ]
parking) (% 0
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
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 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No _�L
IF-YES, describe size, type and location:
City of Northampton S atus�of Per i �°
Building Department Curb CulDkve e..
212 Main Street Sewer/Se
Room 100
�a-r, Weli
Northampton, MA 01060 TwuSets�o` r
phone 413-587-1240 Fax 413-587-1272 Plot%S�te�P, n
f
- Other Specify w -
r --
AP.PLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Propert�Address:
This section,to be completed by office
Map Lot Unit
Zone rlay,District
Elm St. District-___— CB District_ ___
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
S 7,-) ri
Nam rint) Current Mailing Address:
Telephone
Si nat e
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature i Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee `
2. Electrical (b) i=stimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4- Mechanical (HVAC)
5. Fire Protection ',
6. Total = (1 + 2 + 3 + 4 + 5) f i)C3[� 'i Check Number Y Q
This Section For Official Use Only
Building Permit Number: ��� Date Issued:
Signature: _��-- -----------_� _-----
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0944
APPLICANT/CONTACT PERSON CLEMENTE ALAN JOSEPH
ADDRESS/PHONE 5 AUSTIN CIR (413)584-6670 O
PROPERTY LOCATION 5 AUSTIN CIR Pp
MAP 29 PARCEL 356 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 455 SO FT DECK
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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF94MATION 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 Co ssion
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.
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5 AUSTIN CiR BP-2003-0944
GIs# COMA40NWEALTH OF MASSACIWSETTS
29-356 CITY OF NORTHAMPTON
BIILDLNG-
w� I -URMIT
p� 8cltkina .
� BR+2Qf = 4
ft PERM USION IS HEREBY GRANTED TO
coast,class: �'onracaor: License:
Homeowner as.CQnuxtor
C���1AFtu'i�A�M JOSEPH
,nom-��� �,�-
_ mow _TM
VIE Cv AQ
Ti Z77
Annlic�xntA�ess: � memo
5A T C 4. 4- ?
FLORENCEMA01062
TO PERM""T. F0LLGW1, NG WORK:C aTRUCT 455 SQ FT NECK
O T
inspector of Plumbing Gkopeetot'd wbins V.P.W. i t g Inspector
Underground. Service: Meter.: .
Rough; Ron* Douse# 1?twnda#o�a;
Drivsway'makali
Final: Final.
Rough frame;
Gas; e 11!eartient FirepiacelChitey;
Rough: t)i Insulation.
(final; Aoki i Final. 0 K E
THIS PERMIT MAY BE►RIKV01MD BY THE CITY OF NORTHAMPTON UPON N OF
ANY OF ITS RULES AND REGULATIONS.
D te, aid: Q14 N • t
Building 5116/030-.00-00 644 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony PatiHo
MMMEMIMEW