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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
North unpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supra: .• 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), 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
Address of work
location
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DEPARTMENT OP BUILDr)\'C INSPECTION'S
212 Alain Strcct A-funicipal Building
Northampton, Mass. 01060
WC)J UCCIZ'S CO'i\'CPENSATTON MSUTAhC- Al=I AVI
(7i C=-,- Jpermi t'cc)
with a pitilicipa.! place of business/residence at:
c hone �-
°L
do hereby certify, under the.pa.ins 2nd penalties of pc9ury,
( ) I un an employer providing the following worircr 5 coinocnsa:3071. cove arc for Illy
etnplovecs worlDng on this job:
i
(Inmur_n=Comp,) (Polio;?vumixr) (1=;pirrior, D21°)
( ) I am a sole proprietor, general contracor or homeowDer(Ciu cie oee) and lizve hired
Lhe consaciors listed below who have the fotlo%ving worker's coopenI2hon policies:
('Na )c Of Conm; cior) On i ranc: Coinpwi)-Pi obc) } uriL:-)
I
-- (Name of Contraor) (1nsu.r-r_ncc Comoan)•/Pole,• Number) (Ex..66n Date)
l -
(Name of Conrad.-) (Laarancc Compzo)•/PoU-q- ?amNi) (F-xD�r"aon Datc)
(Name Of Contractor) Gnsurancc Company/Policy Numb r) (Expi-,6on Daic).
(nas.Ch t:OC1I 6-1 irncocia,v to cxlu,&inform oo pcz'[a�w.J1
( I am a sole proprietor and bave no one worid.ng for me.
( ) I am.a home owner performing all the work myself.
NOTE:plcsc be t9m=is Mizjc bcmcoµocn Vt-ba cQ�loy pctoai to do -- •^Y s c oo c rgair uoric c� d..c1L of
ant most:the tb ro-tmry to«inch tbx bomoo+wcr rtmda oc oa the�.a�...,,z,�p.Lr a a th=en LT ox ct—D. xerd.�cti w be
ci:ploy--11 the c=-*�cu Aa(GL152s=1(5)1=ppti=6oa try a bomcoaoc for c tie=r_or pcmit Tr--T c id—tL-
le¢I c'L-,=of as c:Ployo under d,.o wockxeL coaxlaom.s Act.
I„ada rtapd that>Dopy olthia mlcmcm oyy be for-+wiled to d-Dc{xrtmrcd of Ind,,�id Acodca&M—of 6--for t6o
covcxSc%,airctioo d-)d Uia L•iltac to Lo=m'covcrnsc trod==clioa 23A cf}.S0L 151 Mn lad to the iarposaaon orcimiai1 pccsw=
coasisi%of a fine oCup to S I}00.00 anNd a=sriz- t orup to Doc yr3r end aril pemhia in 6c form of a Stop wort Order and a
&m Of 5100.00 1 d_y LVLi=me
For M.rur�=�v,c onty
P(T=I Nt ML-cr
Sigi.tium of u—.1--r 1-- Itcc e
55 WILLIAMS ST BP-2007-1239
GIs#: COMMONWEALTH OF MASSACHUSETTS
MU:Block:32C-253 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-2007-1239
Project# JS-2007-001975
Est.Cost: $1426.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq.ft.): 7492.32 Owner: REID LOLA J
Zoning:URC Applicant: John Corbett
AT. 55 WILLIAMS ST
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:611912007 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOWS
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 6/19/2007 0:00:00 $25.002632
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
City of Northampton Status of Permit
Building Department Gub Cut/Dnyeway Perrn�t a - A �
LI 212 Main Street Sew uggoticAuatlabzEity
J tt'
Room 100 WaterlplFE[iAvatlabrfity L 1 a h =rz3
,,. --5M*aNe+sY �rA,-' `.
_Northampton, MA 01060 Two Sets of Structural
phone 43=51240 Fax 413-587-12720 tangy ' ` '
` �, � .. . �.' ...,.a--..�4 m..c •rs�+,—s ry-^�-M"�R�y`�t'�"�: r'i`,�,"� �+s'�x..'^.+ts°'r t4
�-APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
This section to be completed by office
1.1 Property Address:
• _ `Zone�`� `� �` '� O erFay D�stc�cY �� -�" �
'SECTION':2-PROPERTY OWNERSHIP%AUTHORIZED AGENT
2.1 Owner of Record:
-h 610- +�Cl S !fir Li�15 S
Name(Print) Current Mailing Address:
--f
Telephone
Signature
2.2 Authorized Agent:
YA C'C't'_ .q
Name(Print) Current Mailing Address:
7/a-
Signature Telephone
SECTION 3-ESTiMA-TED-.CONSTRUC .1ON.COSTS- a
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building =:(a)Building'Per_mit°Fee
2. Electrical (b).Estimated.TOtal Cosfiof"
Coristruction:from ti
3. Plumbing Bwtdirig�Pennit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3 +4+5) Check Number
This:Section For,Official Use:Ohl
Buildin 9 Permit Number. -Date
� - Issued;-
Signature: -
Building Commissioner/Inspector of Buildings- Date
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 j
Side L:` R:' L:� R: I
Rear
Building Height
Bldg.Square Footage %
7-7
Open Space Footage %
(Lot area minus bldg&paved
-kin
#of Parking Spaces
Fill: I .
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:l
IF YES: Was the permit recorded at the.Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book ! Page; and/or Document#
B. Does the site contain a brook, body of water or.wetlands? NO Q DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Q Date Issued:
C. Do any signs exist on the property? YES Q NO 0
IF YES, describe size, type and location: f j
D. Are there any proposed changes to or additions of signs intended for the property? .YES Q NO 0
IF YES, describe size, type and location: " 1
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 O NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 8-CONSTRUCTION SERVICES
`8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9==Regfis#ered�ltome l/mgrovement Contractor y ; y,-� � ,.,.. Not Applicable-❑
eco cy Zoo t-� /D q 0 C-0
Company Name Registration Number
Qr yt'L 710,10
Address Expir tion Date
--� <.1414 D/D Sr �� Telephone Y?/A--
SECTION 10-WORKERS'COMPENSATION INSURANCEAFFIDAYIT(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...... ❑
17�_t�;�ome��ner�gernp�i"nn
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 buildine 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 PROPOSEDWORK(check all applicable)
71
New House ❑ Addition ❑ Replacemen Windows Alterations) Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding[0] Other[0]
Brief Description of Proposed_
Work: f A-L�-- Y�J�;h c /L�e.;2 y UM 1 5 U 6Xi7-Lrre. s 3
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa if Newhouse ailid o a Id tiorr�o ezistma housi°ngr complete-thy olloinnng:
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
SECZION-7a-OWNERAUTHORIZATION TO;BECOMPLETER WHEN `
OWNERS.AGENtOR=CONTRACTOR APPLIES FOR;BUILDING 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
v-- C as Owner/ thonzed
gegDhereby declare that the statements and information on the foregoing application are true and accurate,to the best of m -nowledge
a lief.
Signed under the pains and penalties of perjury.
Print Name
Sig f Owner en Date