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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton,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 l:is/her construction sups.:is sor. 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).Lnsul4tion 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
Address of work
location
r `
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� 6 fitasaacflnsrtls • --
DEJ'ARF,fEN-T ON DUILDNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMTENISATION' INSURANCE A:FFD)AV.T
,Z z
1 Cti�
"" th a principal place of business/residence at.
------------------- _ _
(StrcC tic ity!:;,7., p)
CIO lief- by Gel–uily, l:il.i':;1- -dic p Ms 2iili 1)C'.i1 itICS OI perjur j', ,Ili!!
I am an' employer providin- the 10110"virlC ••:ol—k-c;S compensolloII cOVCrC:Je For my
elilplovees woI dlT, on this job:
( as-=cz-- Company) e c;Numbcr) ---- (1�piraaon Date)
( j I am a sole pronrieter, general c.on=,acicr `homeovvoer (circle one) and hired
t.hc con—Liaclors hStev be10w :t�Ci't t' Il
l 1: t l T L.10111,;--01-1 DCil,: S:
( lame of�OrlCr 1CiG IISura l OIP.n"::i T •- i r -
r) � ..1CC 'r':�1'G11Cf T1l.tllt'Ci) . .�'sC% �?.t„1
(Name of ConlraCiGr) -- (lrlsur,_nc-- Come_, vfpchc; 'I"TuS,L--r) (l zpiraiioa Date)
(2,,Iamc of Contractor) in; sic t, .,— '`-_.c�_
.-.. .. _�w, ii'ol��. ?vui tf�r) _'.x,. -C:,.. -ale)
- (Name of Contractor) — - (Ins rai�c Comr;y y lloliry Nurnbu) (E::pi-:tiG-Date)
1 i1IT1 a ,�ole 1 1 i . fo iii
2 h011ie O"'vllc. iiCi:Crl?11I1 111 iL i;]';'"lt.
NO"rli:plcsc tK atryc.Ita:•s1'ilc tx<ua�i:m��:-�c:-pL,^.•rr,..��;n:',;-. -•::yzcc,a.-.:>:n:�:m cr:-,:nit«,,:x c-:_�.�cl!i-:,c.
not more th=a lhroc uiilI ir,ui d: he F;i .;tZ, rn:-,cr a;
c^'.pfoycs urk rs the we;},c s cc. re r-r (Ci't.152�=!(Sj;:.-.,: ._:.:ic:;^y a hot i o«xr:`cr e L e Cr
Itgal ctatua of an==plo}'or udder tLn Wo,kce.ia-L•;>vr..tion?.cL
I undc.:taad ifiX!A m y of t}ii c2atc: r_ray bo Iotw ucta�to tl»rYtxi t:rsL of Iz dzu riJ Acrid-&0'i w of i:�.tr�_n for t!x
eovm gc vrti[clioa attd th=t EAurc to t. c co�µc uc 3; cti.i 25.A of MGM,152 can lcui io the imposition r i 1 pa al_u
-(=uting of a firx of up to S 1• M00 an,,,Cr i^::i;rr,zx^1 of::p u)cn:}' r. .l civil perattia in do form cf a S!c;,':1`nY'.Otis_r.;1 1
f
CC S 143.00 a day again:i tn-
Foc d�utin:esl u,c cr:ty
� Pcrrnit Numfxr ._____ �
•
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SiSnnturc of i.icz n_ JPcrnt,,tr.., f .
S1=CTjON 8.=:CONSTRUCTIO.N SERVICES
8.1 Licensed Construction Supervisor: n Not Applicable ❑
Name of License Holder
License Number
Address p� Expiration 'Date
C� tM 1d✓� ( fir+� LK
0/ 042c-
Signature Telephone
9 Reg ste a orne mprouement Go""n a°ctor Not Applicable ❑
Company Name Registration Number
Address Expiration Date
04 nA Telephone l�til�G
SECTION 10 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....... ltk No...... ❑
=p f
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
SEGTIOH DESCR PTI NBpMPOPOSEDMORK check JVJ llta ble � '*
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing 1
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ }
Brief Description of Proposed Work: L T 62 14- N Yott &"t-LY 13/1CP A4 42C
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ • Sheet
a �
CM Me u on ° eeo n oei
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?
It, 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
SECTIOTI7OlNNER AUTHORIZATION 70.13E COMPLETED WHEN
OWNERS 'OR,CONTRACT-611119.P?LlES FOR 8UJLDING':PERM17
as Owner of the subject property
hereby authorize ���l� �' '' %tiG �(1�c I /Z /� to aci on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, 124n'sImull'o,rr� , as Owner1'A0tbr,'zed 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 Ag` ` Date-
i
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
Building Department
Lot Size
I
Frontage
Setbacks Front
Side L: R: L: R:
i
Rear
Building Height
i
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES,date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT 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
IF YES, describe size, type and location:
City of Northampton
Building Department
Y
212 Main Street ,
Room 100
r�y
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
§S4kk+M( Ntit.+rnl�. a �.2 t re
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1.1 Property Address: r
This secfion tQ be completed by ollfce
Eim S D15trICt z r= ..,CBS
strict
SECTION 2-PROPERTY'OWNERSHIPJAUTHORIZED AGENT
2.1 Owner of Record,
r'A RA_ J G C e� ' III n S �►9
Name t) Current mail- W re
C* 6
Telephone s!
Signature
2.2 Authorized Agent:
66
54 11241L
Name(P'nt)., Current Mailing Address:
ltL A 5 •'7 0 L?r�
Signatu 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)Estimated-Total Cost of
Construction from 6
3. Plumbing Building-Permit Fee
4. Mechanical (HVAC)
5. Fire Protection _
6. Total = (1 +2 +3 +4 + 5) L Check Number o
This Section For Official Use Only,
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
4
I ISABELLA ST BP-2004-0888
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-246 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-2004-0888
Project# ]S-2004-1323
Est.Cost: $1092.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin DE Sheppard Roofing 105885
Lot Size(sq. ft.): 16204.32 Owner: CARR ALAN L&ROSE-MARIE P
Zoning.URC Applicant: DE Sheppard Roofing
AT: 1 ISABELLA ST
Applicant Address: Phone: Insurance:
224 BERKSHIRE TRAIL (413) 587-0092-0
CUMMINGTONMA01026 ISSUED ON:3117104 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE BACK PORCH ROOF OVER L LAYER
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• Receipt No: Date Paid: Check No: Amount:
Building 3/17/04 0:00:00 248 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo