29-247 �I I1854A[h1lStttB
DEPARTMENT OF BUILDD\IG INSPECTIONS /=
INSPECTOR '212 Main Street • Municipal Building
Northatnpton, 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 l:is/her construction dupe: sor. Tlie state defines "Homeowner" as, "Per-son;s)
who owns a parcel on which he/she resides or intends to,be, a one or two famit� -
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 r'.egulations. 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 pouf 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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of parillaillpfoll ----_
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DEP/tRTMEI-rT OP DUILDrx,1C INSPEC71ONS
212 Alain Strcct Municipal Building
?Northampton, A1ass- 01060
WOR CER'S COI PENSATION MSURA-NCE AFFMA.All
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\"itb a prtncipaj Pac. o1busli3essfresidencc at:
7� '06�u rlt —/Qe 1410 le w ,hone'!
(sa-�.t/ ty/sca>_c/n P)
do hereby certify, under U.ic.pa_ins and penalties of perlwy, ----hai
( am an employer providing the following!workcr's comocnsaoo, cove--Sc for trey
elnplovecs worlong on Uiis job:
�ZL
c Conr v) (Poticr Nu r) (r:-pirtior, Dpi
O I am a sole proprietor, general contractor or homeowner (ccie one) and lave hired
the conira(:1ors listed below wbo have the ioUo%Vi P, worker's caLoenssaiion pc!icies-
('Namcc 01 CO.!^cior) (Inn rand;: Cotnpan)'/PGUc{ NU-MtC) (—Exmnauon DHLc)
(Name of Coacrzctor) (lnsu-aacc ComDanv/70 m, Numcsr) (LkD'LM6on Dace)
(N.me of Co=d-Io.-) (blswanc; Comp2n)•1P0Uq- Na1mb r) Daic)
(Name of Contractor) (Lasurancc ComGazQ jPoliey Number) (Expirtioo Da1c).
(atISC3=_ddi-:oca1 6cC,irnccc.a:y to atcu&iarormi::oa pc-taiainb to...11 oc¢r-txx�)
O I am a sole proprietor and bave no Coe woridDg for me.
( ) I am..a home owner performing all the work myself.
NOTE:plea be aware it,....i,,Lle bccx) w era Wbo c¢tplay pe-z.tma to t10 -• =-4r-joa C rgair Woric on t(!%--U_j:of
not moct lh n tfsoc tmita in ui=elz the homoowoc rc,ida or eo the p ocwc i,ppurtea zs tbez e e c oue G r11y arsd= to be
eitployes unc'.e the.,-k="Ica Act(GL'1 S2�I(S)),e.ppliaOoa by a bomcoava fez t lick_or pctnit t=y c idcocc the
legal cLa-tu or en c=Ployx uodcr dzo Wotkalc Comp.a—j-;oa Act.
d-a 4 Vy orty" <mma may ba f-1—i-d to tbo DW—tmmy of Ind+artiel A.A—i-'OM—6.1'ltrz ,o-rat th.
cova�e vajr'ciiioa and th1 L:.iltac to to=re lavcz trade 23A of 6idL 152 m ttxd to the i�osiLioa araimias!peaaltic
oona0(S 1 0.a find ortp to S t 500.00 and/or a�ise of up to ooe year tad a.i1 pcaLkja in be fotta of a Stop Work Or de and a
Ciao of S 100.00 i tL•y aptiazt ttx
Fat dcp.rtm=�u, only -
V J PcTIIUt NLLIDbC1
or/l 0 J l.L7p:—_ Lot
Sipsatyn of Lic=LscrlPc ucc e 4
SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Suaervisor: J Not Applicable ❑
Name of License Holder:
License Number
Address � � � Expiration Date
Address Expiration
Y►-t 4Jdj 0 0 A7—o4) Oil
Signature Telephone
3:Re`"ste foi :1m ccrvei►ent+roiztrac qg, AIR ;" Not Applicable ❑
Company Name Registration aum—fir—"— --
Addres l Expiration Date
� 0/c)6 Telephone 67 )0 0
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(WG;L.c.152,§-:25CF6jj
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 buildi94 permit.
Signed Affidavit Attached Yes....... No...... ❑
Q 7rM- �
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
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SECTIONS DESCRIPTION OF=PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement W' doves Alteration(s) Q Roofin
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding [041 Other[CJj
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet sa..ttlVew �ra" se and oreaidifiaaexlst��clrioasrncr:carpet [oarr�lg:
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 7a-OWNERAUTHORIzTION- O B E.COMPLETED WHEN.A Nh IT ONTRACTOR APPLIES FO C OWNERS AGENTORG
I c AP JT7 �l as Owner of the subject
property
hereby authorize �o L 73 e,,A(�
to act o, t1ehalf, in all matters relative to work authorized by this building permit application.
,Gla 0 M1�12,
Signature of Owner Date
-------- --------------
�� r` 1 ieA t2 as(der/Authorized
Agent hereby declare that the statements and information on khe foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
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Print Na .f
Signature ofLlwaeAAgent Date
..rte
Section 4. ZONING All Informatibri 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
Frontage
Setbacks Front
Side L:' R: L: R:
Rear
d Building Height
Bldg. Square Footage } i ! % --?
Open Space Footage %
(Lot area minus bldg&paved f
parking)
#of Parking Spaces I
Fill:
(volume,&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T 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 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Date Issued:
C. Do any signs exist on the property? YES 0 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 O
_ _. _
IF YES, describe size, type and location:
I
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 Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
a n
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City of Northampton -
Building Department G€
.212 Main Street
L - i Room 100
Northam ton;MA 01060
p arm..
phone 413-587-1240 Fax 413-587-1272tott
A FR 2005 oheotf �
( APPLICATION TO CONSTR T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SfC"C[ON.`1 -SITE INFdIVIA'CT
Th1s section to b p
e cometed b�offce ,
1.1 Property Address: _ K
Y
l /U1 ou Zoo !L, q Maps Lot �.Untf $r
x
F 6 P, '.to L rn �., d 1 Zone OuerlayDisfnct
=Elrtt St.District _-- -_.. _., 'CB DistEict _ w
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENL
2.1 Owner of Record:
Name rint')I �j l
Curren0 dr Address:
1"10-
Telephone
Signature `J
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
•,r� �, 5'94 -%/ 7
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building of (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) J -Check Number
This Section'For Offieiaf Use Only
"'D
Building Permit Number. Issued:
Signature: r
Building Commissioner/Inspector of Buildings- Date
3
102 OVERLOOK DR BP-2005-0957
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mag:Block:29-247 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0957
Project# )S-2005-1330
Est.Cost: $8283.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use GroW: Homeowner as Contractor
Lot Size(sg. ft.): 15028.20 Owner: KIMBALT CHARLES
AT: 102 OVERLOOK DR
Applicant Address: Phone: Insurance:
781 Brie Rd. .413) 586-4167
NORTHAMPTONMA01060 ISSUED ON.41x1105 0.00.00
TO PERFORM THE FOLLOWING WORK.INSTALL VINYL SIDING & REPLACEMENT
WINDOWS
POST THIS CARD SO I'T 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:Q k 5--.1 -05
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupangy Si nature:
FeeTyue: Date Paid: Amount:
Building 4/11/05 0:00:00 $25.00
f
212 Main Street,Pllone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo