32C-343 (3) O O
Ll itp of 'Nazt4antptan z
835 RCt�liS[tt5 -
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060 5
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sup{:. :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
Fr 3.c, �,Tc riIjullipfoil -
DEpARTMEI T OP BU(LDD,\C INSPECTIOI.'S
212 Main Street Municipal Duilding
Norlhamplon, Mass. 01060
«`OR1Q R'S COMPENSATION -MSURkNCF Al,
�cc:nsxJ )ttcc) ------
���th a prbi-rcipal place of business/residence at
Gar ?h(Fhonc') �
(sit/ci t J/sZatc/a p)
do hereby cerdf.-, under the pains and penalties of perjury., h2l
( ) I am an employer providing the followine worker's comnensabo, cove 2SC (Or 11)>'
etuplovecs wort ing on this job_
(instir-� Conr�) (Polio: Numb r) -- :piruor DzL.)
O I am a sole proprietor, general contractor or homeowner (curie one) and have hired
the contractors Listed below who hive the following workers cooDtnsallion po!!cies:
('INamc ofConimaor) (Insuranc (Date)
(Namc of Contractor) (Insuuzne; (Lx-Dir iron Date)
(Name of Conn-aci&) (Ianrra.nec Compacy[Pol;-q. Numbzr) (E-,:Di zdon Date)
(Name of Coatmcior) (Lasuranc-- Compaay/Poticy Numbs) (Expim6on Dale) .
(aasr>5-Q'�.1:OCaI L�CC.tr ar.••1--..'ti.�p mGtl�lIIfoCmi7 o0 Pc�ia1111as l�.1.1 oo�-LO']1 t
r
am a sole proprietor and have no one worldDg for me.
( ) I am.a home owner perforn=- a all the work myself:
NOTE:pl=.sc be ewirt Kto ez=:pley per:.a 3 LO d:)_;•.,r,•= =_-e ro c rcpas wocX of
art mocz th-c thfrc tAu in� Wt ch the botnoawacr raid=or oc the p-ouocs�pur� -th,:- rz oo(C-� -Ry cccrd-rd to k
c Vio)cs undo the Kam:c=pc--.:gyp Act(GLI 52-=l(5)�appUc3.6c0 by n boaxo -oa for c l c�__cc pcmn cry nom=LL-c
IcVJ rL-L=m of ea==playa under dra Works,t Coaxpom�Ad
I uad=-=4 dI4 a-opy of thin cauc=us m..y bo for-wurddd to tbo pop�of Aaodua&OIL-of Iraur•ooe foe the
—V-X&e vmsc=210a n•)d 01-1 L•ijure to savrc'cOvcras;.-I sccijoa 25A cf r.(OL 1 S2 can Ie d to the i:,, a o.of a=lwl peazi6=
comismg or a rune OCup to S 1-500.00 armor Orup to roc)c:r=d 6vij pauhia in be form o(a Stop Work Ord--nod n
rum 0(5100.00+day cptinst
For dcp.ruz�:-�u,c Doty
' (sciIILt Nt1II]tX_S
1,/,3 P
Sipiaturc of iccn cclPcrmitt ~ _- Lot
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low
SECTION-8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
J�Rea�sterecfi�ome4°lmproverraentContracxor ,���,,, ,, .�,v�;p; ._,,,, _:.�„,� Not Applicable ❑
quo - G 'P `I'
Company Nam Registration Number
yD �� -4:d-
Address r /fir) Expiration Date
Telephone
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....... ❑ No...... ❑
MAP
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(i) 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
Northampton Ordinances,State and Local 7fning Laws a 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 C]
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [O] Other[0]
Brief Description of Proposed /) 0 C a,,
Work: ��.Q._. /L.�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
saki€�N`�wHIhausandr�a�"c�itlon,.ta ezrstinc>� i�n`g�conipfet�t�e'"i�oTttiu��n :
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;z�OWNER,AU ,HORIZATiON>--T0 BEGOMPLETED=-V*4EN
OWNERS AGENTOR'CONTRAk TOR:APPLIES-:FOR�,BUILDING;PERMIT
( as Owner of the subject
property
ereby authorize
to act on my behalf, in all afters relative to work authorized by this building permit application.
Signature of O er Dale
(, as Owner/Authorized
Agent hereby /Odai4 to4fie 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.
'r CA a61� 7
Print Name
Signature of Owner/Agent U 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
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/Vahunue/Fnding ever been issuedfur/on the site?
�� t-1%NO \~� DON'T KNOW �~� YES �~��
�
/F YES, date issued:
IF YES: Was the permit recorded at the Registry ofDeeds?
NO ~_'i } DON'T KNOW 0 YES
IF YES: ' enter Book Page and/or Document#
�� ��
B. Does the gtecontain a brook, body of water orxvet!ands? N0 �_� DON7KNOVV �~� YES ��.
IF YES, has permit been or need tobo obtained from the Conservation Commission?
Needs tmbeobtained Obtainmd /~\ Dmte |ssuad'
U �_� ' '
C. Do any signs exist un 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 0 NO 0
IF YES, describe size, type and location:
E Will the construction activity disturb(clearing, gradingexcavation,or filling)over 1 acre orind part ofm common plan
that will disturb over 1acre? YES ���� NO ���)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
DeparFrnenfuse one -
City of Northampton Status aPsraa� "
Building Department
212 Main Street
a
Room 100 v tl x
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 °
+ tie
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1:-SITEJNFORMATION
1.1 Property Address: This section to lie completed bytaffTce
3
� 20 OuerlayD�sti^�ct
4�
�-E1mSC,«D�strict;Y� L� _-< �CB�D�stnGt '
SECTION.2PROP ERTY`OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
61 D-X,4 TelephoneS RG i y yZ
Signature
2.2 Authorized Agent: j
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 .ESTIMATED,CONSTRUCTION`COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by-permit-applicant
1. Building Permit Fee
2. Electrical (b)Estimated Total.Cost of
Construction..from4 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This.SectiomFor Officiaf Use Only
.
Building Permit Number.. Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
t
27 BREWSTER CT BP-2007-0520
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-343 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-2007-0520
Project# JS-2007-000758
Est. Cost: $4600.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Larry Paquette 100679
Lot Size(sq. ft.): 4486.68 Owner: STANDICK TRUST RICHARD RESCIA
Zoning: CB Applicant: Larry Paquette
AT. 27 BREWSTER CT
Applicant Address: Phone: Insurance:
40 East Green Street (413) 527-6375
EASTHAMPTONMA01027 ISSUED ON:111312006 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 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: Date Paid: Amount:
Building 11/3/2006 0:00:00 $50.004145
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
27 BREWSTER CT BP-2007-0520
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-343 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2007-0520
Project# JS-2007-000758
Est.Cost: $4600.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Larry Paquette 100679
Lot Size(sq. ft.): 4486.68 Owner: STANDICK TRUST RICHARD RESCIA
zoning: CB Applicant: Larry Paquette
AT. 27 BREWSTER CT
Applicant Address: Phone: Insurance:
40 East Green Street (413) 527-6375
EASTHAMPTONMA01027 ISSUED ON:111312006 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 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: Date Paid: Amount:
Building 11/3/2006 0:00:00 $50.004145
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo