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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building 5 •`�
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as hls/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'Ue hvo fan_y
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 lull i g department for the City of Northampton wants-any persons)vho-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 dour) 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 the work can be ins ected.
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
L 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 -
Dates
Address of work
location
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DEPARTME14T OP BUILDI)\'C INSPPCTIOI'S
212 Main Strcct Tsunicipal Building
Northampton, Mars. 01060
WORSa. RIS COM PENSATIO.N MSURANCF
%Vl b z principal place of businessfresidencc at: — -
.���- 1�� v1�1 e•C.f= �.t ���-�`-�. ��i4 G%�c�.::y � ():h on e�') ..S c��:� 7i •�---
I (scrrt/ci tylsiatcrzi p)
{ do hereby cer6Jf,-, under the.pa*us azd penalties of petlury,
i ,
j ( ) I a m an employer providing the follo%vinQ Iv,,orkcr's compcnsznor. covcrv�c For III)
emplovecs worlong on 11iis job:
{ (Esau-mac Conrz.�) lPclic: ?tip-n.irr) t=:•pir`tior. DzL}
1 ( ) I am a sole propricror, general conuacior or homeowner(ci cie one) aDd have hired
the coouaGiors listed below CYbO have (be ',oUotvi.nQ wor tier's C.0, Ltat�0 pOIJCIes-
(t=-, Oi ConEnCiO") (In2ranc Companyi-Poiic; !"ruII1=cT)
(Name of COD U:CZor) Ri urancc Comnanyi?o!iey \u»c_r) - (xpx m6on Due)
(Name of COaII-dclo:) Gmsuranc: Campam/Policy 1v;tmb r) (>_:cpij-a non Daic)
(Name of Conmac-lor) (Lr—,i=cc Company/Policy Numk) (—Exp r26on Dais).
(a—ch:d3i�ocsl to¢�cl iafoc G oo pcta n as to.11 ooc-sv�)
{C I_am a sole pr=oprietor and have no one wo6;3.ng for me.
( ) I am..a home o,vner performing all rbe work myself.
N07�:plcs be curare tt,. c bemcx4 ocx��o czaplay pe oai to cl�t`i=t=•^ ca-r�ao c rc3ir orx an d cLL^.�of
j aoe moCt 11 !ter-='rj is wbkh the bo,�raid.oc oat the p-o�ata, �tb,-, r noe C=�=Uy oe =d_-ni w be
1 perc pioyca= the U _c m- - Ac (GUI52,=1(5)�=ppiia7oa try a b xm --fc b�-or m r--:Y c,,d�ec the
1cpI c==or ea c=*loyeruod.,dr Work; -,CocaQom-•Si ArL
I uOdc-c- d that a oopy ortbi.=.co-w ovy bo foe+an!eC t.o the Depa,,c ,orIod,s j A, &.a:(C15-of Irr.—foe th<
j - cov='%sc vcr6c=tioo sad lkut U=c to scurc'covzmcc tn]dc zociioo 25A of MOL 152 can led to the 6co or c-'m;z.t PCO 4:3
eoasi;axh of a rwc orup to s 13oo.00 arwor 6,opr6oaa,of up to ooc yc_r Lod aril pco-_Y,io in�fowm Ora Slop Work Ordc azd a
i
fim 0(5100.D0 a day,pia mc.
For d�.na'1t u.c only --•-'-�
{' permtl Numt-_T
1v(ap-^_ Lot
� Si�istzt of Li
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SECTION 8-CONSTRUCTION SERVICES t I
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of license Holder:
License Number
Address Expiration Date
Signature Telephone
Reaistere i 'ornemD o emenoirtracfor 'T` - $#
Not Applicable ❑
Company Name Registration Num er — —
S c' d: K�� t�r"c � r t7�t el
Address Expires Date
e�fct `3 —Telephone S ,(, 2-1`L
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...... ❑
MAW ,
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.
Defnition 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 be/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 hirc 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
r
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SECTION 5 DESCRIPTION OF PROPOSED WORK(check°all applicable)
New House ❑ Addition ❑; Replacement Windows Alteration(s) Roofing
Or Doors Cl
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[06 Other[b
Brief Description of Proposed
Work: t`✓r'i <<r'"!—�1 `-: Z+` �.' .'I y' �� s lc
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.1#New hous"= nc >"�ddi ioh to exis tinal oustncr-complete the fovu nq:
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-OWNERAUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR`CONTRAGTOR 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
as Owner/A thorized I
e3t..hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my kno ledge
and belief.
Signed under the pains and penalties of perjury.
Print Name �
Signature Agent Date
'–'
Section 4. ZONING All Informatibli 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
(volurne,&Location)
'
A. Has | Permit/Variance/Finding ever been �suadfor/on the she?
' �~� �~� �
K0 �� D�7 �OW �� YES ��
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DDN7KNOW YES
IF YES: enter Book Page, and/or Document#:
B. Does the site contain u brook, body of water orwetlands? NO «���� DO07&NOVV �~� YES
IF YES, has permit been or need tobo obtained from the Conservation Commission?
~
Needs tobeobta[med v,~� �bta�na� �~� Date �ssued'
v�� \~�' ' '
C. Do any signs exist onthe property? ��V YES �~� NO ^��
IF YES, describe size, type and location:
D. Am-there 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 or filling)over 1 acre or is it part ofo common plan
thawN|disturbnver1onm? YES � � NO � �
`~� ! ~—"
|F YES,then u Northampton Storm Water Management Permit from the DPW is required.
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City of Northampton
Building Department
K' h
- \ 212 Main Street
m
- Room 100 e
i� Northampton; MA 01060 0
phone 413-�87-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to�ecorrapleted Uy office
c� f �iVlap Lot: .t"? Unit
t
§4 El �Distract CH D4stnct
SECTION 2-`PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Recorder n
Name(Print) Current Mailing Add, s:
Telephone
Signature
2.2 Authorized Agent:
/c�Vi�t✓ C-��.l�f'>/ I V _r_4s /L1i1
Name(Print) Current Mailing Address:
-�� 4.j-- �- -Y'- '�1,'��')/�/—
Sig ure Telephone-F-SECTION 3-ESTIMATED CONSTRUCTION COSTS'
Item Estimated Cost(Dollars)to be Official Use Only
completed 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) '> 5 Check Number
This Section For Official Use Only
Date
Building Permit Number Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
. $0,14W
82 BRIERWOOD DR BP-2006-0209
GIs#: COMMONWEALTH OF MASSACHUSETTS
MM:Block:29- 182 CITY OF NORTHAMPTON
Lot 00 b-
Permit: Building
Category: BUILDING PERMIT
Pen-nit# BP-2006-0209
Project# JS-2006-0305
Est. Cost: $2525.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq. ft.): 10018.80 Owner: POMPILLI KENNETH S
Zoning Applicant: John Corbett
AT. 82 BRIERWOOD DR
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:812412005 0:00:00
TO PERFORM THE FOLLOWING WORK.-COVER SOFFITS & FACIA & GABLE ENDS
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 8/24/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo