29-186 (2) O �
Grifp of Wort4ain pton L
V 0HSSRChIiSttt6
r
{y DEPARTMENT OF BUILDI7\'G INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building
Northampton,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-,;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
f
r
s
IE GIN of 11allip!Lill
g - 6 ;i�cssRClltrcctts '
—
^� DEPAR1'h1-NI OP LUILDI?�G INSPECTIONS
212 Main Street ' Municipal Building j
NOrtl amptoll, MRSS. 01060
NN'Or CER'S COMTENSATIOIN I SUTZANCE I FFMAVI-T
------ — — -_
(Ii ccn&°1zJ rnlitt c}
'v th a princip,-2 place of busiress/residcc](:,e
UC
d0 1lCI Ct)y cCrCil}: fill:' 1' t11C• tt) lms and pC n It1C:; 011 pCr�llS '.A1i1
I am zm employer providin- the i0 10`.`,'i:':S '.':Oit;C1`S colI9pCnsS,. ]oI] cOVCIf: C for :n),
employees `vor�dng on dies job:
(Ins>ranr' Coclp2m') ^clic:Nutnbcr) --- (Px:rir,-Oon D21c)
r ) I am a sole proprietor, -entt-L CoTI=C`cr o'F homeovvrler (cLc!e one) a_ d, 'gave iditd
the, contrwtors IISte,C beJo w-,v'10 the. iO} ".y i;P " OiitP�S CJi peIl�~Oi: '0!iC:cS:
(1`><t1I1;C of CoriLractor) �n_`LPncG Lvlri^?'i:/l Gild TvI 1tIlt' i) (T x .ntic-, Datc)
(Name of Contr<c`,or) CoII1D,cm,Pollc-,, NtnYrr) (I >:piratin Date)
(Name of Contractor) Date)
(Name of Contractor) (Ins Iacic Cot,, yfPolic;; Nlumbs) (;I ;:ni ::io: Date)
�..".II.1G7.`.d-�I�CY:11 S_:'�S.....'... ::] ..-_..-..�...:'Y:^.a..Ci:,.-._-..:t:� ..ii.':(:::_..--..•)
i
t '+ p 1i. )'- .�,. t , t y � 1': ll
SU L t.l"O j. 1�C:.: c!..1 Ili.` LO Oi ', �,..,-iii.; for .I �.
<1i11 llOillC 0�'t'?1C: 0`IiliI'! , all
NOTE:plcac be at4-arc that .r ilc lwC co,,IY.} c:--,!Cry ;n ism cr
not uK-cc thsn three unit3 in«-Lie't or oc;'`�- -:c f',-'<Cerrraliy cr ;;t.r:: :J tv
calploycr.s urv�' thr tvcci,�s cc T-=atim.tat((-,71.!'2.s:(YO,a,:l.i_::icr`by thoc:roltncr`or t Lcex a
legal rtawR of an ezaploya under tLn Workcle coz,�r .tion?.cL
I urndc-rtt nd thL a copy of thi,ctatcis•c:xy bo fot}v.vd-3 tot;-Dcjxi Lx,ccz:of l.c>d>._lirid Ac6&i Y QtFicb Of::1'rir.a For lltc
cove yai jc:Eoc and th^t failure 25A of MGM,152 can feel to the imposition
ooaiisting of a flrr-of up to S 1.M10.00-n�'c r of tip to Cr,.}- r.:-.j civil pcnaltia in d C I<mn cf+Stc;`;v' Y C}1i=tad t
f t�of S 1 01100 1 d.1y gpun:.i m:. .
._,l ,, Fcr cirt-,,:vinti.l u•a ortfy
Pcrrnit Numtx;r __-------------
.t
Simmu cofi,ict:rcJf'crnliac: F
' w
1
M
SECTION 8 CONSTRUCTION SERVICES
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
IReg slime edfl' me//�,mWAFS"Vement°a ontracto" 2 - - - Not Applicable ❑
oce ✓v rG L fit 91000
Company Name Registration Number
r—
SG
Address Expiration Date
S �l iC Telephone
•,SECTION 30 WORKERS' COMPENSATION INSURANCE-AFFIDAVIT 152, §;25,0(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...... ❑
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
ggg
SECTt01 = OPOSEYOK DE 0% check ill:a I�cable x
,� Y-i• ,.. .. ... t �5-';iR!:'.i 'GRR¢, ..:..:..xcx�s'S3,m. „_.: ...Ti}wv'wmiaYn4AaP!.<>.: ,.i..:_"uG`,.e:51. ..'#1a�,,;„<' x� .;-i. .
'., "3'ua4 rrv: vr�+raraxaaa' *tg,,,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: cayc_..r— i L-A�, .�--
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll 0 • Sheet❑
sa 11 ew""11 o"fse M oF-VaZUit16 ff exisung1houfi:h omp�e #he&"fol;lowifit.
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?
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
SECIOt ;77OlNNERAUTHORIZATION TO BE COMPLETED ;WHEN:
OWNERSA�ENT�ORCONTRACTOR.AP
PLIES FOR BUILC�ING.PERMIT'
I' as Owner of the subject property
hereby authorize to ac.; on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/ horized Aaenntt `
hereby declare that the statements and information on the foregoing application are true and accurate, to the
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Ow r ent Date
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
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
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:
R '
City of Northampton
Building Department
a
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 _
n ,
w
APPLICATION TO CONSTRUCT,ALTER, R IWNP.VAP R 'A ONE OR TWO FAMILY DWELLING
3f
M AY 2 7 2CO4
SECTION 1-SITE INFORMATION
onto be completed by office
1.1 Properly Address: I ,
a r sus
YQDeF 3 -x ?OVerl�DlStnct �
,
" Etth St DISti'IC� � �c� � `�1D15trICt ,v_
SECTION.2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�-�L•�'� ��/l>iG�— / f! r!`�' / `ice'�+ .V�'_eor'( L r_��- �h
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
J�4 yy Y-: e
Name(Print) Current Mailing Address:
,5-741 IF 7f `--
nature Telephone
SECTION 3—ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 'Jay Building Perr ii,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) e'�S Check Number "
This Section For Official Me Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
126 DEERFIELD DR BP-2004-1206
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29- 186 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-2004-1206
Project# JS-2004-1833
Est.Cost: $2965.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: John Corbett 104000
Lot Size(sa. ft.): 15028.20 Owner: TORREY WAYNE P&HELEN F
Zoning:URA Applicant: John Corbett
AT: 126 DEERFIELD DR
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:5127104 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:
Feel e: Receipt No: Date Paid: Check No: Amount:
Building 5/27/04 0:00:00 1911 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo