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DEPARTMENT OF BUILDI7\TG INSPECTIONS
INSPECTOR '212 Main Street • Municipll Building
Northunpton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as hds/her construction sup(.:-,;sor. Tlie state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two famz-Vy - -
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 0gulations. 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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T 3 of �arflj��lt}�tnll _ _-
��aSti[C'1 RL[IIt
w o DEPARTMENT OP BUILAI7\C INSPECTiot.'S
212 Alain Strcct Municipal Building
Northampton, A1ass. 01000
WORKER'S C0,61CPENSATTON MSURA.NCF A17FM,,iATj-j
/(t;ccnsa-Jpertn;ttcc)
with a plZncipal place of businesslresidence at: ----- -
�?5,� ' �k'--� �1� 4,37l , 10 4) )kA(phone`') s'SG '�1
(sB�t/city/ iaP)
do hereby certify, under the.palnS and penalties of perjury, h:i
(t�ll am an employer providing the following!worcer's colnpensadon coverage for Iny
emplovccs worUng on this job:
U-)C, 6-- C -21 112 �•• ly /,5'h-; o �
(Insuranc Conn n.) (Polk,-Numbcr) (r:xpiraaor[Dat.)
O I am a sole prooriecor, general contractor or homeowner (crcie one) and have hired
the consa(nprs listed. below wbo have the FoUo�vinQ worker's caGnenm-aon pokies.-
Rolm-, of COnt^cwr) (InRlralic.r- Coinoan)-Pi obci Ntumh---) _:JIiJ O?l�atC)
Y
(N:mc of Coo (LIS-,U72ncc- COmoaa,,-j FOLIC-, Numcrr) (Ex pir.:aon Date)
I
(Name of Condor) (Insurance C"ompan)'/POL-q- (Expiraoo Daic)
(Name Of Contractor) (Insurance Comraay/PoEcy Numb-zr) (-xpi-z ion Date).
(aQX.3 '��-oCa1 c'.KCf.truce.U--v to mGu.&tafo[lnazioa, .
-may In�U com--=On)
O I am'a safe proprietor and have no one working for me.
( ) I am..a home owuer performing all the Nvork myself.
NOTE:pl�sc be atritC Ifi..M WG ua�q�wLCf1 ti by�tQy pC-IQnl fS7 -.• Y -r�uo c rcpzv-oric as[d..�1L y of
! ant mete t!`n two tmta in tr'sch the botnootvnc rt7id�«oa the pvuac i x�purtco zs t r 1y oc dai he oot to t-
-avloyea unec the 0==P oa Aa(GUI SZa l(S)) :pptiaooa try a homcoavc fcr a lien=or pamit=y cvidcocc tl:c
lcg�l n.n,,o:as mloyer under dto Worker[Cooapoon.tioa Ae(-
[uoderta,pd tha a copy of thu m.y b<foa-w d.d b the p op,ftmeen of Ind riJ Aendoe[a'O(G_or l[z.—X+ for th.
coves S v%xiGesliao and d_t C_=.c to r.==)wvcr,�tinder scGiioa 25 A o(),(dL 152 eaa laid to the capoitioo olerimiazi peaittic
coauj:m3E of a fine o(trp to S I X00.00 an&or o(up to ooc y,=r end a,.il pay.tia in tt c form of a Stop W orE Order and a
(tin of S 100.00 I&Iy apron M>-
For dcp.n -,t u,c onl7
Permit Numb--x
t.4Z p. Lot
SttnacurcofLic=ucclpc cc --
SECTION 8-CONSTRUCTION SERVICES 7 r:
8.1 Licensed Construction Supervisor: d Not Applicable ❑
Name of License Holder: '�' �� � 13 ��'/1 r)"7/
License Number
Al
Address / Expiration Date
Signature Telephone 0 /
C7
b
Mt.
Not Applicable ❑
Comoanv Name y} Registration Aum er_ -----
1;7 A10
Address ) Expiration Date
/A(�S'� �;r�t�a r 7`0 � 3-� Telephone 6-W
SECTION 10-WORKERS'COMPENSATION INSURANCE.AFFIDAVt (M.G L.c 152,': 26C(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 build g permit.
Signed Affidavit Attached Yes....... No...... ❑
y 4
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 buildine hermit.
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 Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [E3] Decks [p Siding[0] Other[
Brief Description of Proposed
Work: /J-5 7'f!I/ 0a!t Ct Gyt IV 0 c�•''�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
� -ate � ._ � �; '. . ...., _�,�?�+,�;.
$a i Ner+u iraus"- rt AMM04ia to�exts i�t a�sina�,+� mo a iif>< fi%
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 Ta-OWNER'AUTHORIZAT ION, TOBE:COM0LETEB'WHEN.
OWNERS AGENT':OR CONTRACTOR APPLIES FOR B[)1[6lffG PERMIT-
�73� �
I, ��m G`j ,as Owner of the subject
property 7�
hereby authorize
to act n my behalf,in all matters relative to work authorized by t is building permit application.
7 cz ' ' ® �
Signature, Owner Date
L 2 A c) - ,as r/Authorized
Agent hereby declare that the statements and informatioh 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 Na
Signature of C3'MdAgent Date IF
Section 4. ZONING All Informatioh 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
� � II
Il � I I
Frontage
Setbacks Front l
Side L:i R:= L.' ; R:=
Rear
Building Height ! -
Bldg.Square Footage 1 % ? I
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?
N0 0 DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page; F and/or Document# f
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued: I
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location: j
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q
3 I
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 r NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
_._ .
City of Norte .mpton i
-
i�i(lding Department
11212 Main Street
Room 100 e
N.AY - �ho`>4541i
� 3 58/-1240 Fax 413-587-1272 °.o
APPLICATidN TO CONSTRUCT, LTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
`SECTION 1 -SITE INFORMATION
1.1 Property Address: �� Thtssectron to be CamIetd"6office
V u n
All N (2-y r �o Ut�
Qt
p�,� INK,
r �
/9L-M /►' Zone` E O�erla"'Dts�rrcf
a
Eltnt D[str[ctaCBDtstrtct tt
SECTION 2-PROPERTY'OWNERSHIPIAUTHORIZED AGENT;
2.1 Owner of Record:
Name(Print) Current Mailing Address —�—
Telephone i
Signature 4f 36,Y 7
2.2 Authorized Agent:
ILI
Namg_(P,jint) Current Mailing Addre :
Signature Telephone
SECTION 3:-ESTIMATED°CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
om leted by ermit applicant
1. Building 7 5;- (a)Building Permit Fee
2. Electrical --� fib)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 Sectiorr For,Official`Use Onl
Date
Building Permit Number. Issued:
Signature: r
i
Building Commissionerlinspector of Buildings- Date
41 HENRY ST BP-2005-1104
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32C-315 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2005-1104
Project# IS-2005-1499
Est. Cost: $6198.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sg ft.): 5488.56 Owner: BAK JAMES A
Zoning.URC Applicant: B & R Siding
AT. 41 HENRY ST
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:5110105 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 5110105 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo