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DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060 5`
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to
act as has/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 backfilI),
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
understand the above.
(Rome 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 �- 1 s1 t1k;l ��
�0
,F E (rii� �f �L�n�fl7i:z111}�tal) - _-
R J E �;a�a+crhrtsrtta' _
DEPARTME1,T OP ➢UILDr\,C iNSPPCTiol,?S -
212 Main Strcct Municipal BuildinC
NorthampLon, Mass. 01060
VY O_Rl2 R'S C O�,1P L N S A TIO N -CN S L7RA.N CF A IF?M;{Vn-'
(licc'nscxJperm�ttc�) ---
v-rich a pi�,-tcipal place of business/residence at:
{phone')
(srrt/ci ty/statt'a P)
do hereby cerdi --, under thc.pz-iris -nd penalties of perJwy, hal
( ) I am an employer providing the follo%vine tvorkci's coinocns-nL)o, cove Ige for fin
emplovecs wor�Dng on this job:
(Insir--n=Comr,�-:m,) (Polio: Nu_bcr) -- (r:-piraon D2=)
( ) I an a sole proprietor, geoeral contracor or homeow-Der (code on(--) and have hired
the conma(nors listed below who have the foUotviDQ worker's comptn_u.ilion pokies:
(NNam: 0. conmlaor) Onsurznt„ CoirnOaSl)•/PoUt-i
(Name of Conm-acior) aas-aranc°. amoan".1Po!ic Nunccr) (—Exvirlion Due)
(Name of Co=da,) (Lasuranc Company/PoUq- NumbJ) (Expirzdoo Date)
(Name of Coamcior) ansurm(m Compzay/PoLcy Number) (ExpLmdoa Dain) .
(aau.� i�ocal dcct,ir ncccxi_1•to c'cud_iafocm�oo pctaiaias to.11
{ ) I am a sole proprietor and have no one worldog for me.
I am.a home owner performing all Lbe work myself.
NOTE:plcsc be aw-art tt•r•wiJc bcc c=,ocn w'bo ccc=play pcsoas to do =—,,=a r t pair work ca.d«1L of
mt most t—tfrm—j is w tx c the bocnowvcr rtzido o,oa the Qv wr 3 tpptu�the :ooc r lry occnd=,cd to LIC
eitploytrs 11 the w-ka'z c==p ;oa AC(G Lt 52 n l(5)},:ppli=.6aa by a bomeow-oa fa a Ge5 o:pe-mit rzy a-rde d-`
I<-F.l ctaau of as oegloyer uadar dao Woriccla Compom.iioa Act.
[uoda-rtaad Iba a aopy of thix=ac m y bo for O dad to the Dcgertmco¢of A=&.Iy C'Moo of ira—fx tb,
oova-tb-e v=ificlioa and that Lihat to sca=tovense t=dcr section 25 of MGL 152 c=Ie d to the i1rruaiw of a'imia+!pm•'16
oo¢si-TAt of a fiat or up to S 1 X00.00 arldlor or up b ooc yt3r and Civil pmahia io tr fo m of a Stop Wort:Ordc a.od a
rim of S 100.00 t dy tpti=Mr-
For deyanm=-o1 u.e enly
t Numbcs
n
S i gna tum UC i [X/p c tTiti cc l hip~ -- Lot ° J
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
m «.. b ... ��
9 "RecliserectRdmlmprouemenontcacto Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT,(M:G:L.c.1'52,.§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-awn-&parcel_ofland 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 wi the State Building Code,City of
Northampton Ordinances,State and Local Zoning Laws and State of Mass chusetts neral Laws Annotated.
Homeowner Signature �� r
L
SECTION 5-DESCRIPTION OF PROPOSED`WORK(check all applicable)
New House ❑] Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[0] Other[0]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes_�No Adding new bedroom Yes J No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
s�,�l�ew� o sea >�tioz��o�ex>ISt�cr'� ousl~na�cornpir �oCibvi�g
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?
1 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-,7--&OWNEF2 ACfTHORIZATION TOTBE£QMP TED WHEN -
OWNERS":AGENTAR:CONTRACTORARPLIES FOR BUILDINGsPERh
Ir 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
ner/ orized
Agent her?hy declare that the statements and information on the foregoing application are true find accurate,to t my knowledge
and belief.
Signed under the pains and penalties of perjury.
Print Name
ignature of Own Ag Date
'
Section 4. ZONING All Information 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
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location) LI
A. Has a Special ncling ever been issuedfor/on the site?
eN
NO DON7KN0N kj YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO � )
__ DON7 KNOW YES
IF YES: enter Book Pagel and/or Donument#
�� ��
B. Does the site contain abrook, body of water orwot|ands NO v�� DON'T VV v��KNOW YES \_f
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �-\ Obtained y-� Date
�_* �~� ' .
C. Du any signs exist on the property? YES 0 NO G�)
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E Will the construction activity disturb( hng.gradin g Zeavation,
or 0|ing)over1 acre orioit part ofo common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
r a� �-
Building Department
212 Main Street
w.
e
Room 100 r,
Northampton, MA 01060 - �
phone 413-587-1240 Fax 413-587-1272 ..
t
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION:1.--,SITE.IN FORMATION
Th�ssectroww" co pletecl ykflffice
1.1 Property Address:
Cap ¢
INN 777
SECTION:2-PROPERTY OWNERSHIPIAUTHORIZED,AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
/S'
Telephone
Signature
2.2 Autfrorized Ag t:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION=3=ESTIMATED>CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant -
Building (a)Building Permit Fee
T. A6 06
(t)Estimated-Total Ccst of 2. Electrical Construction:from. 6
-
3. Plumbing Building Permit Fee'
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
ThisSection-For.OfficiaLUse Onl
Date
`Building Permit;Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
25 HENRY ST BP-2007-0355
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-311 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-2007-0355
Project# JS-2007-000525
Est. Cost: $6000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 85377.60 Owner: SZAWLOWSKI JEROME J&SUSAN M
Zonin.:URC Applicant: SZAWLOWSKI JEROME J ' SUSAN M
AT. 25 HENRY ST
Applicant Address: Phone: Insurance:
25 HENRY ST (413) 586-3286D
NORTHAMPTONMA01060 ISSUED ON.912812006 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:
FeeType: Date Paid: Amount:
Building 9/28/2006 0:00:00 $25.001538
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo