38B-042 (2) of Wart4anipton z
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building
Nordiampton,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 has/her construction sups: ,•isor. T he state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fame
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 r',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
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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R E .91 r7 a It chnrclla• —
DEPARTMENT OP BUILDr\;G INSPECTIONS
'j 212 Main Strcet Municipal Building
j Northampton, Macs. 01000
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WOR14;R'S CONITENSATION MST- A CF AITI)A IT
(li ccnsxJpermi ttcc)
\%riLb a p zcipal place of business/residence at: - —
(phone=')
(sty Lld rr/sla.ttt a p)
do hereby certify, under tie-pains and penalties of perJury, :hat
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( ) I am an employer providing the follo%ving iworkcr's coinocns-zoon cove gc [or Inv
emplovees «'orlang on dies job:
(Imzu-an= Comm,) (Polio:Ntnn�-r) -- (r=:-pir-,or. Daz^-)
I
O I am a sole proprietor, general contractor or homeowner (c cie one) and Lave hired
the cone actors lined below who hzve the folio%ving worker's policies:
(Nam-, of Con naor) (ln2ranc: Coinpan)•Pto6c Nru nh----) -''J1id Q�DILC)
(Nzmc of Contractor) On.7w-ancc C.omoa.ativPolim, Num6cr) (-Expu-tion Dae)
(Name of Connaao.) (Insuran= Compan)•/PolJ-q- Numbzr) (Exairdon Daic)
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(Name of Contractor) (Losuran Comp aay/Policy Numb r) (Expintion DaLr)-
(a x1r� dpi or�1 cSca.l ncccs.�•u cad t�iafornr 1 oa pca to iaaas to.11 Dori
a sole proprietor and bave no one working for me.
( ) I am,a home owner performing all the work myself.
NOTE:plesc be ea-arc q—wt }c bca,=a mcra�bo emplay pcsoai Lo -•0, c=.—e oo�rrnr,.ori on.d..11_�of
aot moc<tl + b—ors in ut2kb the bomoa-v r mdo«oa th.p-ouac4 zppurtea:=tban= :we C–.J -Uy«cr:d.-rc i to tic
i c::Wlay=une--the..= c=mpC="tiea Act(GUI S2s=1(5)�applinDon by a boa=-=fm e licxv-a PMMm I ruy c�id Doc the
l�r n_^�•of an-=play",.ceder d�worf.o(,coazp.�-t,;a.a A�t-
I
t uadcsraad thA a copy of tbio car.oa=my be f— rded to the D�partmco¢of lnduzrial Acs &_&CffMoe of I--roc tb.
covarx&e vCrif moo a-nd Uu Liltae to saauc tovcrstsc ta�da soesion 23A of}14L 152 ne led to the iaritioa of crimiast pea+ltias
eoaz;smg of a rive ortp to 51300.00=rAfOr ia�riyo or up to Doc yezr cod a%i1 pauttio is 6c form of stop wok orde and a
F1m of S 100.00 t d_y t¢iast me
For
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S Permit Nttmlxr --
G����� Lot a
19nauur of Liariscc/Pcnrnitrcc —���
SECTION 8-CONSTRUCTION SERVICES r
8.1 Licensed Construction Su ery sor: �� Not Applicable ❑
Name of License Holder: (/7! C G�
License uN tuber
Address 1U, / Expiration Date
Signature Telephone ) /
:fie is ere Horned royernerllContracito Not Applicable 13
Company Name Registration Num—Ter -_-
Address Expiration Date
Telephone
SECTION r10-WORKERS''COMPENSATION INSURANCE AFFIDAVIT(MA 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...... ❑
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The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(]) 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 Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑:;. Replacement Windows Alterations) ❑ Roofing
Or Doors ❑ 1 0
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [p Siding[0] Other[o]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedr m Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa lN��in� oseYantlia trexis int ttousinar=cvi nQtthafiTowirix:
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
SECTION Ta-OWNER AUTHORIZATION,'TO BE COMPLETED WHEN
OWNERS AGENT.OR�CONTRACTOR APPLIES FOR BUiLDING•PERMIT
I, as Owner of the subject
property
hereby auth rize
to act on behalf,in all ma rs elative to work a thor¢ed by this building permit application.
a _ C
Signatur of O r Date
l ,as Owner/Authorized
Agent hereby ec re that the statements an information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed un the pains and penaltie perjury.
Print Na
Signa u of Owner/Agentf(f Date
.
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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 7-- % 7-1
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume,&Location)
A. Has | Perm�/Vuhance/Fndi ever been �suedfor/on the s�eY
' x�� «��
K0 �� D�7K�W �� YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO �~��
� DON'T mvuvv ,co
IF YES: enter Book Page' and/or Document
B. Does the site contain u brook, body of water orwetlands? NO \�� DO0TKNOVV «_� YES
IF YES, has permit been or need to be obtained from the Conservation Commission?
~
Needs mnbeobtaioed x�� Qhtained ^�� Date
x�� �.� '
C. Do any signs exist on the property �� ��� YES �°/ NO v��
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:
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre orind part ofo common plan
that will disturb over 1acre? YES C @ NO K B
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|F YES,then a Northampton Storm Water Management Permit from the DPW is required.
C[tv of Nortf ampton
ilding Department , ,`
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212 Main Street _ n .
J Room 100 h_
JUN 2 7 LeUb No 'hampton, MA 01060 s <
phone 41T-5F-1240 Fax 413-587-1272 '
^r 6".,APPLICATIbN tWC"ONSTROCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1'-'SITE,1NFORMATION
3 This section to be completed by offce „ ,
1.1 Property Address.
;Mapr ,L-ot � llntt,
��i��' "� .Zone � Overlay Distctct
w
�Elfin St Distract - �__ ` �CBDisinct.
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(P t) Current Mailing Address:
Telephone C —
Sig ture
2.2 Authorized A ent:
Nam (P nt) Current Mailing Address:
1'-7
Signa re Telephone ell
SE ION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
c leted 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) Check Number
This Section For Official Use Only
. Date
Building Permit Number. Issued:
Signature:
+
Building Commissionedinspectorof Buildings Date
2 EDGEWOOD TERR BP-2005-1304
GIS#: COMMONWEALTH OF MASSACHUSETTS
MV:Block: 38B-042 CITY OF NORTHAMPTON
Lot:-001
Permit: BuiidinQ
Category BUILDING PERMIT
Permit# BP-2005-1304
Project# JS-2005-1749
Est.Cost: $7000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin James Roberts 117154
Lot Size(sq. ft.): 6490.44 Owner: JEROME JEFFREY M
Zoning.URB Applicant: James Roberts
AT. 2 EDGEWOOD TERR
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTON MAO 1027 ISSUED ON.6/27/05 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF
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 Sienature:
FeeType: Date Paid: Amount:
Building 6/27/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo