29-229 (2) 4'iHAMP�.
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5i {y DEPARTMENT OF BUILDING INSPECTIONS I
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
'"''�► act as iris/her construction sup: i sor. 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 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
o4�tV MPTO ( -\
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m DEPARTMENT OF LIUIL NG INSPECTIONS
212 Main Street > Municipal Buil(IinI"
Northampton, Mass. 01060
WORICER'S CMATENSATION INSURANCE AFFIDAVIT
(]i Cz-nscdperm i ttec)
%vith a principal place, of busMess r-esidence, at.
(strc:t/ci tylstatc���p)
do hereby certify, under the pains and penalties of perjury, that_
O I aril an employe;- providing the following_ colnpcns:.tioll for lily
employees Working on tliis job:
(Insura-nc Company) (Pclic;Ntunber) -- -- -- (E�pir.tion Datc)
O I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed beiow who have the fok,v"Eig workers compen lion polices:
(Name of Contractor) (Insuranc:, CoirnanylPoliq, Nmnbcr) (L>:p_�-a oa Date,)
(Name of Contractor) (7nsurince ComDa;Iv[P011c}' Nunbf r) Date)
(Name of Contractor) (Insurances Comj ao)/Tolic� Numb,--r) Date)
----------- — --
--------- --- ------ -------
(Name of Contractor) (Insuraucc, Comr,:r'ry/-Poticy Numbs) (Expi Maio:; Date)
(atladi tbdi`imal cG�ct iF r.eces,r:::�ixl•xic i�orms:ia:x-tainin�•.:;ell,c:^ado:+)
i
I mil it sole proprietuur i'_nd have no one ;,'orkir, for me.
O I ain a home ovine: a!1 the v"ol r;]vsclf
1i0'I�i:p(caac tic ntrarc tl:ai.4t_ilc Ix�txo��2r_rs�+moo a;ploy y��s to,'.:c��1cav�c�arrn:��m cr; pair.� •.. .._�«cll�.�cC
not mere thn tluco units in Nst:d't Lhe!u kourrs rcjid-.w or«t 1, cn —7wrten-ill t acu)e r(x<Fe,xralty cc::d� d:o h
c�ploycs u.� cz die t�vcl:�a cc�:—:alien At (GL152 s l(S)),a{pl: .lie by a hom,i o«NrKf fore Lcn:x cc
legal rtatus of an o�lo}•x under ti:o Wor4cera Cotnpmial-iom Act.
I undcntx d diu a cmy of thiv ctatrn--a muy be fOcA-vrdod to tln 6cpartax of Indi»rial AD66�1&0ffl of I:::iY for tin
cover-agc verification and that fnaiurc to more oovcmgo un&r:ccticn 25A al l.iQL 152 can I"to tho imposition of mnin l pct all:u
coosisting of a fux of up to S 1,500.00.:III or i riso xrcnt of up to oat:}t r and civil pcnaltia in dr fcmn of n Sic \Vxt Ord-and a
find 0(5100,00 a day regain:.i m--
Fordq;utrrrstal oily
06 Permit
Lot
_�,�1�,.f1,� tgnaturc oY L[ccn_,cv'Pctnt ttc:: ��L�'
SECTION 8CONS�TRI)C. I';O,N SERVICES!
8.1 Licensed Construction Supervisor:^ Not Applicable ❑
Name of License Holder : �""�' 1�K L-/A C (P-4 /
License Num er
130 Lodes T`r' 'P-6R6 HJ,J _17461�� W. 41054 S a�
Address � Expiration Clate
Signature Telephone
�Register�ed rite nprbvement Co'�n actor , - W Not Applicable ❑
- cam mi-Cf04 /b ZY/R(0 �o c(ST1Pd�iz /U , g 7
Company Name I Regis ation Number
16W771-1&FD-%( A44 0 0 16 l_s- /0-?
Address Expiration Da e
Telephone 4(3 &(,o 33S$
SECTION 10' WORKERS' COMPENSATION INSU.,RANCE AFFIDAVIT(M.G.L.c. 152,-;§ 250(6))11
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...... ❑
MAE, o 4l n.
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)famiLes
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
A.
SECTION. :-D S b R ah 041 PROPOSEMW0HK�cli'eck all a `' licabhe
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: 1T-IZIP E(tSn4G 7-Mc('4b ,r ;r-V5'rW- , NdEct 45^46
Alteration of existing bedroom Yes_X_ No Adding new bedroom Yes X No
Attached Narrative❑ Renovating unfinished basement Yes 7X No
Plans Attached Roll ❑ - Sheet❑
MN h�o se" a�n"'d o a�laition to existi k4KOUS'ing, dotnpffle 'Mr lio M.
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. 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 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 fOWNERAUTHORIZATION - TO BE COMPLETED WHEN
OW NEFtS�'AGENTOR�CONTRACTOR APPLIES FOR BUILDING`PERMIT
�70(I� �f E,QEee i as Owner of the subject property
hereby authorize -��f� PI/4&TZ)14 to act on
my behalf, mall matter relative to work a hod by this building permit application.
gnature of Owner Date
- i4CK
W4(-7V-4 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 pen ties of perjury.
Print Name
�
Signature of Owner/Agent D to
Section 4.
- ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
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 _ C
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:
"r City of Northampton S at
Building Department Curb tuf�+D e
AY Room 100 Wa erJ
212 Main Street S w
M:a, 1 v 2'G3 we va t,
Northampton, MA 01060 Ta et ref f
p hone 41,3-58.7-1240 Fax 413-587-1272 Plo /Site p an„
`
V b
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 be completed by office
17(c lqe 11 F8ROC7K 691 VE Map Lot Unit ` r
6LOPE14 CL MASS- Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(P Current Mail/no Address y/
Y A_
Telephone
Signature
2.2 Authorized Agent:
Name(print) ! Current Mai!ing Address.
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Emated Cost (Dollars) to be Official Use Only
completed by it applicant
1. Building :]; sti
�zoo.00 (a) Building Permit Fee
2. Elect.,mcal W, >timated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanics! (HVAC) ---- ----------- — -
5._Fire Protection
6. Total = (1 + 2 +1+Z4 + 5) _ Check Number _
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: — ------ -- --- — --
Building Commissioner/inspector of Buildings Date
r BP-2003-0996
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
L� -
�
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0996
Project# JS-2003-1596
Est. Cost: $4200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Jack Walton Construction 107687
Lot Size(sq. ft.): 10018.80 Owner: HEBERT DOUGLAS L&MARY J
Zoning•URA Applicant: Jack Walton Construction
AT. 176 ACREBROOK DR
Applicant Address: Phone: Insurance:
130 County Road (413) 667-3358
HUNTINGTONMA01050-9727 ISSUED ON:5112103 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 Shmature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 5/12/03 0:00:00 2303 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo