29-221 (2) 0 0
Grztp of Mort ainp ton
�A'35ACh7iSttt6 -
DEPARTMENT OF BUILDI)IG INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as }:is/her construction sup c.-,i sor. 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 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 roueh 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.
( o (e 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
Cizft�i of �I>rz tl1�tltt}�fc�tt �.
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DEPARTMENT OF LUILDD) G INSPECTIONS
212 Mahn Street ' Municipal Builciilig
1"7ortharmpton, A1nss. 01060
WORKER'S COMI TENSATION INSUTZANCE AFI'Me,'V71T
i,
(lic�rstJi'frnlitt��) —
Nvith a principal place of busiress/r :,irenc
C{O 11CfCU}' CCrL1I}' l:a;' r" Is :'.iic7 peil 1t1C-i Chi
( ) I am an employer providing the follovv;nt ;:orr_cr's compensation covera e for In)'
emplovet;s working oil this lob:
(L=, cc: Cornp?m+) cli .N,i nErr) ----- (-rte rir ion Datc)
I aci a sole pro>7nctor, honlco:wner (cLcle onei and l:a,e lured
t.l,e contractors listed below l:o the `oll c, .._:; rjork°rs c�il�en�aon o}i .cs:
(Nnrac of Cunt, ccor) (In_umlic Corno;.r;r,PclicJ ?lurnlYr) �x .:rack- Datc)
(frame of Contactor) (7ltsur,rce Cow�ar_v�Pe!ie; Nilrnb-r) (I :Diratin.:Date)
(Name of Corit23clOr) (Frl 1 3I1CC C.�u :!il'i/POI:c: TV11.rIl1f i) Sj.` C' 1%aic)
(Name of Contrlctcr (I - n - 1 -- ,r )
J ns ranc Cos.: }'.l o1i r atiu.m °*) (F :rl-:tior D< e
(Cttldl:.U•{I tl CC:11 S:YCt::!:!ir-.1:':lD•�-J.�',-^'-`(Ca::::K:�-3._.... .. eL J:Qb:"_i:(•: .
i
( ) i Iun a sole propriet �r i!il;i have [m on l ur':.ir,i' for nlc.
I Sill �? home Qw?lC` iiCi ,`In1I'^ `!II t'.., -,-.,r ii It
NO I :'e.-se be a,ra c tha a`•ile f cca it . enp! ;>. t�a ._ rsant�a>::_n r m or:.,?air.+ ..__...
not lnccc th.n throo uni+i in«a.idt r= s x a; ' .•_..:z z •r.r�r+tF c o c 2 n.{Ccrtal2,'err; t`
c^'-ploycs un',cz tiv (6L!52�s!(Sll.a+:;i,::ir_.; y n hn:•_t onncr for n Lmx C-7
]egal etatun of an amp Oyer under tin W cq kccfI Cori,+m_-_anon�.c-
I undo-zta nd Ltir!a cmy of tha elate:s•r_uy�fa«nrurl to tl»fY_Siart�un:of Itvliu:riJ M.id�:�'LI icw of::::=u�.a for tix
oovcragc vaifirlioo and tlh t f ltuc to c- c mtYr�ut 3:u�.iM 25A of MG1,152 c_tn lead to the imPositioa o(cr i:_i
comiY.ing of a fin-of up to S I S J.CYJ n:t�' c i :nr.r.Z c;!of::p to rr..)-W r.-.I civil pcmllics in u�f;nn of n S!r `s"cr!'
L of S 1 U�.pO a day irtin:i m..
- Fac dcpuvmcsl L'":!y I
�z2� t=may. I q__ 5r -rJ rrttu�fy r
rnit
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inns urc cif i.icc:r•;c.^ 'crnT;itc: i-.ir`.�_- i c
D,
S'ECTiDN� CiJ.NSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
e s e om mProare ent Con#racto „ Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
�Sl~CT ON�10 WOR�(ERS' COMPENSATION-iNS.URANCE FFI DAVIT ftG: c
L.. . §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...... ❑
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
—�
w a x
SECTaO1�JN.A ES°F Iex ONtGF PROPOSED;.WORK checW. I a Nca'ble �p ,
° -
New House 0 Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. F. Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other (�J
Brief Description of Proposed Work: T„ .r J�ILI
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll O• Sheet 0
" a .:eat .a n `°'��it=ion to existing�h uo si°ng r�rtaple�liefol�owin�
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 r/ 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 Nc
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
SECTI117 F WN�E�3�1U O IZATfON ; TO BE COMPLETED WHEN
$OV`�GNE�tSA 1+ CON RACTORAP.- FOR BUILDING,PERMIT
as Owner of the subject property
hereby authorize to act or
my behalf, in all matters relative to work authorized by this wilding permit application.
Signature of 0 ei rte— Date u 3
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.
Print Name
Signature of Owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
V� 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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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:
- ----- f Northampton
r L C E Q �s ing Department
?! ' 2 Main Street
! Room 100
S F, 1 8 2003 ' '
J Nq a pton, MA 01060
L
phone 41 58 1240 Fax 413 587.1272 P o r
DrvT O* Rill'n!'G wlSPcG?l0's
I .
ILI
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1!-SITE INFORMATION
_ r
Y
Thisz5ect�o k beomp»`e Eby ffic ,
1.1 Property Address:
EIr St
I, rict . f CB D.is�tr ct • "
SECTION 2 -'PROPERTY`OWNERSHIP%A uTH6A1ZED-AGENT
2.1 Owner of Record: ,tom
a m rr 1 ��/� 1 tip / �e i'�s b ✓uD j� r
Name(Print) Current_Mailing Address:
///r v c
GGc� �.y Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTI'ON,3�-''ESTIMATED .CONSTRUCTION GO�STS
Item Estimated Cost(Dollars) to be Official Use"Only
completed by ermit applicant
1. Building -A00 (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
Building Permit Number: Date Issued:
Signature:
Date
Building,Commissioner/Inspector of Buildings
112 ACREBROOK DR BP-2004-0304
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map•Block:29-221 CITY OF NORTHAMPTON
Lot: -001
Permit: Buiidinci
Cate pry: woodstove BUILDING PERMIT
Permit# BP-2004-0304
Project# 15-2003-0637
Est. Cost: $1200.00
Fee: $25.0o PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group Homeowner as Contractor
Lot Size(sq. ft.): 10018.80 Owner: HATHAWAY RAYMOND L&PATRICIA
Zoning:URA/WSP Applicant: HATHAWAY RAYMOND_ L_& PATRICIA
AT.• 112 ACREBROOK DR
Apnlicant Address: Phone: Insurance:
112 ACREBROOK DR (413) 586-0964Q
FLORENCEMA01062 ISSUED ON.9118103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WOOD PELLET STOVE
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• 67 x sL�_
O jf
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON V�OLA.TION OF
ANY OF ITS RULES AND REGULATIONS
Certificate of Occu anc Si nature:
FeeType: Receipt No: Date-Paid: Check No: Amount:
Building 9/18/03 0:00:00 5355 $25.00
212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo