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DEPARTMENT OF BUILDIT;G INSPECTIONS /=
INSPECTOR '212 Main Street • Municiral Building
Nortliwnpton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as 1 is/her construction sup,': zksor. 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 fame 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 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
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P f�X7LRrhnrc(In _
o DEPARTMEN7 OP BUILDr7\C I2,4SPPc7'101.'S
j 212 Main Strcct Municipal Budding
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Northampton, A1ass. 01000
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WORICER'S COi1'fPENSATZON MSURANCE Al FMS rr
(li ccnsxJperm�ltcc)
\VILL a principal place of businesshesidenc.e at: ------ -
(phone')
(st V6tylstatr:�ap)
do hereby certify, under dic.pa-ins and penalties of per3ury, :hat
( ) I am an employer providing the following i%voricer's comocasador. cove Mee for Iny
etnptovees Nvort3ng on this job:
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(IDSul-m=Coax ) (PoLc:Nt ter) C xpirarion D2--)
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O I am a sole proof-ietor, general contractor or homeowner (c cue one aDd heave hired
t-he conuactors listed below who have the following worker's coE.ioep_',adon policies:
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(NIMC Of Coet^czor) (Insulran(;e. ColnDan)vt'oucy N1um'_cr)
(Name of C000-aaor) (lnssrance Comoaativpolim, `u-mcrr) Date)
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(Name of Coamclo,-) (Insurance. Compan)•/Poucy Nulmbcl) (Expi z600 Date)
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(Name of Cooaaaor) (Innlran Comcany/Policy Numb`r) I, —,aoa Date).
(nua.c3�u::ocal bcd,ilnct�z.a�•to a�c!uc�iaf•Eon pclaiai.ac Lo.11
O I am 'a sole proprietor and have no one worldog for me.
(�� I am.-a home owner performing all the work myself.
NOTE:plc=sc be tcrzrc it— +'1 10 bem vm to mplay
P'==LO do c- c_-,woo c rc Iav-aric on.d"�-8 of
On(mace lh=d tmtr is-bkh the bomoouvcr raido a oo the V-. zpputtcn_r1 tbeeo c.-c oa(C w _11y Ooc=:d d to be
ccitploycs untie the ca=ps-=tit A=(G01 52,=1(5)�:pplia600 by a bomco-=fm c fir=m or p emit r=y c%-rdrooc the
Ic Va cta%c or a.a e=:Ployx under duo Worlcolc C.ompomalioa ,a-
. I aiadaita,ad did a Dopy of thi+mt.®cs may bo focwurded to(bo Dcponmme of Indaarrici Acedr�t!Oltoe oC 4rr++nnoe for tb.
ooveLsc v=-iratioo a d th1 L-iltu-c to saauc toverase vndcr soc on 25A of MOL 152 as lad to the i P 03 of Qimio_+1 peailt
eoazi:.i og of t fioc of up to S 1-300.00 and/or or up to Doc yur e-od a Nil pmat im io dx form of a Slop W orti Orcie Lad a
run of 10WOL d_ Lpi¢A me
- For dcp-,=11 u. only
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Pcr-mit Numb=
lA3p-" Lot
SigoaWztofLio=scrJ ct7nittcc —��
SECTION 8 CONSTRUCTION SERVICES +
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature - Telephone
9 ate sPere' ame�lmncaernerroiitra +ate" - Not Applicable ❑
Company Name Registration-Num er -"------
Address Expiration Date
Telephone
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...... ❑
1 o e M!
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 thir.Dermit.
The undersigned"homeowner"certi d sumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and oning La 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 [0] Decks [M Siding[0] Other[0]
Brief Description of Proposed
Work: ` 1( t 1�� /�'I L<'r11 �- 1�(- t�(.�� t— Lx 15 nt"J c,—
Alteration of existing bedroom Yes ;4,'--No Adding new bedroom Yes
Attached Narrative Renovating unfinished basement Yes _ —No
Plans Attached Roll -Sheet
',61 €4' vW orx5e�n�or.adtli rra#o exrstinc lO slnaF:cureutete tM ol16WIinct:
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 constructio nsions
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 wetl s? Yes o. Is construction within 100 yr. floodplain . Yes No
j. Depth of basement or cellar flo below finished grade
k. Will building conform to t Building and Zoning regulations? \water No.
I. Septic Tank City Sewer Private well Ciply
S ECTION 7a-OWNER AUTHORIZATION.-'TO BE COMPLETED WHEN
•OWNERS AGENT'QRCOiVTRACTOR APPLIES FOR BUILDING:-PERMIT
LI as Owner of the subject
property "f
hereby '7 ----- -
to act on my behalf,in all matters relaf u oozed by t 's_building ermi tion.
Signature of Owner Date
NE4 AQ LJ 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
� G
Signature of Owner/Agent'; Date
Section 4. ZONING All Informatibh 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
i E i
Frontage
Setbacks Front --�
Side L:' Rr L:' R:'-- 3 4
Rear w
Building Height
Bldg. Square Footage 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?
NO DONT KNOW 0 YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book = Paged 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 1 Obtained 0 , Date Issued:
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C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location: s
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
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 , NO
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IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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Cit of ortPampton
R(Bui Department
in Street
m 100 r
V rth n;AMA 01060 a
:` y
J ,; OCT��j pF+iorle -58 - 2 0 Fax 413-587-1272
f APPIA ,( IQ4Iit1CT,AL ER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
_,� Thts section to be'completed by office
1.1 Property Address:
Map�� :Lot � ' Untt
OyerlsWDistrict
1 Elm sr,Distract f t u sca Dtrict
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: Q�
Name(Print) Current Mailing Address:
-411
Telephone
Signature
2.2 Authorized Agent:
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
1. Building Z 4 (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 Foe Official Use Only
Date,
Building Permit Number'.', Issued -
Signature:
Building Commissioner/Inspector of Buildings Date
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47 HENRY ST BP-2005-0388
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Blocks 32C-318 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-2005-0388
Project# IS-2005-0519
Est.Cost: $2400.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 36982.44 Owner: HOLDEN THOMAS C&MARGARET RICE
zoning.URC Applicant. HOLDEN THOMAS C & MARGARET RICE
AT. 47 HENRY ST
Applicant Address: Phone: Insurance:
47 HENRY ST
NORTHAMPTONMA01060 ISSUED ON.1016104 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL METAL ROOF OVER EXISTING
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• Receipt No: Date Paid: Check No: Amount:
Building 10/6/04 0:00:00 256 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo