32C-268 (10) �„Stu1`tP�.
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building SV,
Nordiampton, 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 super,•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 famiry -_
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 Notthampton 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 f egulations. 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
and
L understand the above.
ome owner/r s' ent's signature requesting exemption)
11 call to schedul ,all required building inspections necessary for the building permit
issued-to me.. z _
9
Date / 4� J
Address of work ,
location
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o DEPARTMENT OP BUIL.Dr)-,,C INSPPCrt01'S -
j 212 Main Strcet Municipal Building
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Northampton, ATass- 01000
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-�NtO RICE R'S CONQ'ENSATIOV G SUR A-NC}✓ AI<FMA.VIT
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v-1th a principal place of business residence at: - -
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(phone.!)
(Su=Uci ty/sza.tcla P)
do hereby certify, under the.pains and penalties of penury, ih�t
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j ( ) I am an employer providing the folloWing!workcr's comocasado, cove mge for Im
emplovecs «vor>3ng on this job:
j
- I-�c Conn) (Polier Numbcr) -- (r':-pirraorr Dzie)
O I am a sole prooretor, general contracor or homeow"Oer (c cie one) znd liave hired
the cona-amors listed below wbo have the following workers coMoen_c2.Don policies:
l++^!I2°. Oi Co1f^1Cl(]"} (1Rstranc; Cornoi-1}-iPouc,'
(N:me of CouTz or) (lnsuranec Comoanw?oum Numi:-:r) (EiDirztion Date)
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(Name of Coun-aaor) (Insvranczz Company[Poucy Numb,--r) (E-xpirrdoo Datc)
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(Name of Coun-amor) Closurancz- Comcaay/PoUcy Nuna&u) Dkc).
(aII�Gj1 �oc31 cScC.if nc��_-ti-co mcvc�iafo�m�.�oa pclasa:a6 to au ma=---=.O=) -
i
O I am-a sole proprietor and have no one worid-ng for me.
( ) I am..a home owner performing all the work myself.
INOTE:plese be awNr ]e 6cmco,,),a uto etaploy pc.c=to�Sa -, r—srj-m a rr3air warn m c ^�of
aot aocc t t`.per tests is the homoa-vc read.oc oo tE,pgouac:S z.r--purt,n the... c ox C==-12y cti�d.-.d to Le
ei:ploye-:unC.-the�.ui;cz~c�•.•,�-•_,:en P.�(GL11 S2:a 1 CS)��^PlinDw by.bomma�a fC a t��-«pewit�y e�i3moe�e
Ic-P.3 rsyrc of ea-=ploy,.uodor da.o Work-e-Coo3p...4;va AcC '
�, [uodcsr;cd tb.a a Dopy oC t1ai,mtcmmt Daly bo foci-�+nrd.d to the L)cp.ttmcca of Ind.+sricl Acodccca'Off oe of[r>�+om for th.
coversr rcire=ioa and th1 U-==to socuc bov=11Zc I=d---o oo 23A of MOL 132 m 1--d to the ia;=ica of criminal r c-1ir;c
ON tine of tp to S 1500.oO arwor iso oCup to ooc yc_r e.nd civil p=.1ua is 6c focm or-Stop Wort Ord-and a
fim of S 100-00 a day
For:..�.-r•••-'•t u.c on7y
O j� Pc=-t Numb-
t�taotrc of Lice crmitl= --Late I
SECTION 8-CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
Reasf eEeHortrefircioveriteitaitracta Not Applicable ❑
Company Name Registration-um er
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE.AFFIDAVIT`(M.G,.L.c.'152,,§25C(fi))
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...... ❑
�olll r � m
om
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-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
J N rthampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
omeowner Signature
r
SECTION-5--DESCRIPTION OF PROPOSED WORK(check alt-applicable)
New House F-1 Addition ❑. Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding(0] Other[O]
ief Description of Proposed cam` aJY ov-L wrV a<
Work: 7
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa ff-`[�fev ro�rse n arc dstco to ex�s i�ic ores tc .cor pet the aura g:
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 AGENT OR CONTRACTOR-APPLIES''FOR BUILDI@CG.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
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.
fry 13 S A)
Anat me
r
e of Ow nedAgent Date
—UT ke
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Section 4. ZONING All Informati6h 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 Spaces
(volume,&Location)
A. Has a Special Perm it/Vohance/Fndi ng ever been issued for/on the site?
No 0 DON7KNOVV 0 YES 0 �
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO KJ DON7KNOW 0 YES
IF YES: enter Book Page and/or Documant#
�� ��
B. Does the site contain u brook, body of water orwet|en� �� VV v��� NO «�� DON7K0O YES �~�
IF YES, has permit been or need tobe obtained from the Conservation Commission?
'
Needs tobeobtained x�� Obtained �~v~_/� Date�~� ' �
C. Do any signs exist on the pruperty �� ��� YES «�� NO �~�
|F YES, describe size, type and location:
D. Are then*any proposed changes to or additions of signs intended for the property? YES �~\ NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb grading,excavation,or filling)over 1 acre orisd part ofa common plan
that will disturb over 1acre? YEG � r NO 0
_ / _
|F YES,then a Northampton Storm Water Management Permit from the DPW is required.
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on
d► impartment
_ Street
rr 100
4 S E P 2 3 I ha ' " n; MA 01060 zap efs s� Str w*11an s
___.phone 413587140 Fax 413-587-1272 oite ? ns � r �
APPLICgpgo"Tl�.�'N'!�c$�°1—TgR,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
S CTION 1 -SITE,INFORMATION
1.1 Property Address: Thrs secttan;to be completed by office
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�j p ("(/r �lL t! 'nyv-Lg ST Nlap Lot Unit
12.—Ct+4-0,1 'rp/v Zone Overlay`Dtstncf
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�EIm Sf;D[str[ct _ .. _. CB
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
EA n ture
41/9Allfhorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
Building fy� , (a)Building Permit Fee
2. Electrical O (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) Check Number
This Section:For Official Use Only
- Date
Building Permit Number.: Issued:
Signature:
Building Commissioner/inspector of Buildings--- Date
30 WILLIAMS ST BP-2006-0322
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-268 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0322
Project# JS-2006-0467
Est. Cost: $800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 57934.80 Owner: GIBSON JOHN S&
Zoning_URC Applicant: GIBSON JOHN S &
AT. 30 WILLIAMS ST
Applicant Address: Phone: Insurance:
30 WILLIAMS ST O 584-3419 O
NORTHAMPTON MA01 060 ISSUED ON:912312005 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE
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 9/23/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo