32C-340 (7) ¢KHAMfi7'
"g Crzty of Wort4ainpton L z
Jt ass a Chits efts
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060
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 supc;::• 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 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 signatute reques. 'ng exemp '�on)
I will call to schedule all required b,it ing inspe tions cessary for the building permit
issued to me.
t
Date
i
Address of work
location 3.
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DEPlu2I'NfENFT Of' BUILDP? G INSPECTIONS
212 Main Street ' Municipal Duilding
NIorthamptoil, Mass. 01060
NV RICZTS CONITET''SATZON INSURANCE /,F+'F IDAVI.T
1 � c,
vrith a principal place. of business/r-:id^nce
do hereby certif�;; I'll;i r the pens it.nci pelt;hies o pcs�usy, t.ha?_ -
I am an Crllployer providing the iollo`..,Im✓ comm—ms<Uon cove"a"•C for illy
employces worEng on this job:
(Las-1I°dIIt~ Company) (P 0;;C NtLantxr) ---- (`rte. •ir a�a Date)
< j I am a sole proprietor, ge'nPrai can c?or -Jr homeow-Der (ciicle one) and tla,:e hired
the contra=Ts liste-d be'iovi ;,-ho }?� ih f01� .�i;r 'v�Orne�S COIDpeI1S3 0i1 ;0!iS:cS:
(Name of Contrictor) (tsisu nce Corn^- icy Nwn�---r) Dmc)
(Name of Cont_r<c',o:) -- (7 Lsl ;nc Con�_r /Pelier NlnLrr) (Fr tin Date)
(Name of Contractor) (LIL 1 ?S1C d_Ou ;;? 'ili Of;C: l UTI]1r T) -\ f i.0 Dale)
(Name of Contricior) — (Insoran�� Colilrti,�roLicy Number) - — : :.:alas Date
I ani i. .;ole propTlutUi
121I1 <: 110111e C, C7 'tiCilC'I'.11I1� 111
NO"TIi:p(casc tc ntra c ti:;: .ti ilc :-n:c—m Cr {?ai:.
not tz ere lh n tluoo units in\,iacdi.F_�1:: ;, ,-re < c,-oc;'` :_.._s c •r cr r Lhcc o c n t�crrally uv;: rc :a t�
c^tployc3 un?cr t}>r:vc:i:c _cc x• :_ica Ac,'((-:-152, z 1(5), b.t-ncowrr.x for
lC911 rta.tua o£an cMQlo}'or under tL•o Worlccel oc^;o=.lion IXL
I ur,&c.-mot, d th-1 cQ?y of tlx:, my bo fo w—I J to t!r I ct—t--re of Industrial Mil�:s'C:roo Of for 11x
coverage vcrific=liod and tlt•.t failure to r, c co,6-T--M ut 3 r:olio-2 SA of MOM.152 r_w lcsd to tlx itn(:asition o;
comistvng of a I•tr),Of up to s 1-SOO.Cvj a:tnr i-::r. y :4 of::p to cr. }, e-.7 evil perultia in d<f(wnn of n Sty)':Jeri-.0 d.a_rd a
Lrn of S I Q4.Ni a d_%y qp in:1 m..
r cr dq=uvn-metal a ro coil y
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SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ) _` Not Applicable ❑
Name of License Holder : Z Q:-f• t l7cX� V 6S ob z--`15
Licens Number
u oc, o vi� -k e rl �c .Qt3��)
Address . Expira ' Date
Signature Telephone
e e e :omex rue / rac .w. Not Applicable ❑
Company Name r, Registration Number
rca -
Address - �� a+3� Expiration Date
Telephone Aje- d
SECTIONxWbRKERS' COMPENSATION INSURA:NCE: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...... ❑
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
i
SECT' LUA ROM
KwiMaV, ROPOSE MORK checkia'II-a licable
. � � gam, .,
jn '!•°.,,-w` ` -�a::,.-'.sue##,,: ,s` »r w v ' .r;:.. ,� aNH -,. .. °' :', »>rP
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofin
Or Doors ❑
Accessory Bldg. ❑ Demolition[) New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No Cl "
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 11
6a. ;:e -o a n" it"iontoexstingfi.u:s"i=ng, .c nao p:e3=e fiellowing
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 .
1. Septic Tank City Sewer Private well City water Supply
SECT. ®1� 1(i► ER1 �UTHORIZATION TO BEd MPLET.E. WHEN
Ol�t�tERSA EN7 �CONtRXACTOR APPLfES FOR BUILDING PERMIT
k
10 '" as Owner of the subject property
hereby authorize to ac;. on
my,be alf, in all matters._refative�to work authorized by this building permit application.
Signature of Owner Date , "
I, l r/'Authorized Agent
hereby dec are that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed un_� pains and e J of p rjury.
Print Narxxe
Signatur of Owner/Age t Date
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
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:
i
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413.587-1240 Fax 413-587.1272
�P
APPLICATION TO CONSTRUCT, ALTER, f P/� 2,I$ t`4O,VkTl` R �E i H A ONE OR TWO FAMILY DWELLING
°"
I!
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SECTION 1 -SITE INFORMATION
1.1 Property Address:
Elrrf,St District .._ACS District
SECTION 2 PROPERTY OWNERSHIP.%AUTHORIZEDAgENT
2.10 ner of Record:
Name(Pri Current Mailing Address:
Telephone
Signature
2.2 Author' ent
C-0 1z.A- 143
Name(Print)-f' \ Current Mailing Ad s
Signature Telephone
SECTION.:3.- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be icial Use'Only
completed b permit applicant
LP � Off
1. Building (a) Building Permit Fee
2. Elec:,rical (b) 7stimated Total''Cost of
Construction,fro.in 6
3. Plumbing Building Permit Fee
4. Mechanica! (HVA(--)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section':For Official Use On'ly.
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date'.
T
122 HAWLEY ST t BP-2004-0359
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mw: Iock:32C 340 g CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2004-0359
Project# JS-2004-0517
Est. Cost: $865.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group. ROBERT D THIBODO 118441
Lot Size( q. ft.): 6185.52 Owner: DION DONALD R
Zoning.URC Applicant: ROBERT D THIBODO
AT. 122 HAWLEY ST
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527-8966
NORTHAMPTON MAO 1061 ISSUED ON.9/30/03 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL RUBBER SYSTEM
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 9/30/03 0:00:00 1790 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo