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DEPARTMENT OF 13UILDINIG INSPECTIONS I /:
INSPECTOR 212 Main Street • Municipal Building
North,unpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNIR 108.3.4 to
act as i:is/her construction sup(:.,,so.r. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,a oweor tiwo famiy -
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 buil ding department foi the City of Northampton wants-any persons)-who-seek-tv
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 buildine 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
L 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
r
i
Crib Qf {Orf11alliploII - [
o DEPARTMEITT OP 11UIL.Dr>\C INSPPCTio?"s -
j 212 Alain Strect - Municipal Building
Northampton, Afars- 01000
. .... .... -
WGIUCEI IS COINOENSATION ONSUR—NCE Al'i JJJf .�1A'
(li ccnsxJpera>;tfcc)
,kllLb a principal place of busiaessfresidenc- at: - - -
(phone")
(sn-rr.,t/ci rr lszau/a p)
{ do hereby certify, under thc.pasns and penalties of perjury, ihai
( ) I
am an employer providing die following!v.orkcr"5 comocnsabo, covemse for Iny
elvptovices Nvol�zng on Lies job:
- (Cesar-mac Coax ) (Folic:K-u—LY I) -- ( ,piration Dzz=.)
i
( ) I am a sole proprietor, general contractor or homeow-Der (ci:cie one) and have hired
the coairactors listed below vqbo have the `ollowing worker's GOC20eP—taaon pOkles,
j
(N=-, O- Cont=c-'Or) (In--urancz Comoaalyill oUCi NU-Mb::) 1111c)
(Namc of Conamclor) (l.nsuazcc Comoanvv?olie: N1un62r) (1=.vDira6on Dale)
(Name of Con=do;) (Innlrancr. Comnan}-/Polio}• Namber) (Expirraon Dalc)
(Name of Contractor) (I2a1ra.nc-- Compa¢y/policy Numb-`r) (E p'bon Date).
(arsdocil .itn�.-.-- -}•ca c�cv af«m�on pervIa:ng to.0 oc,�-r�:a) _
O I am a so-Ie proprietor and have no one working for me-
( } I am.a home owner performing all the work myself.
NOTE_plesc be.wart t-x +-1::}o hcmca ivc s v.'bo ley pe= Des w do -• cs ciao a rc-zir work as.d. th--Z of
oat meet tl`n ` it pis is�c1se's the bomoo.�vc raider or oa the Umra6,�pusten =t2ra c c ox =>r-!iy eC'cid.-ed to t+c
ei�loye"uaGc the�.ui of - ---*ea Act(GO 52..-.1(5)).appU=t 6 a by a hommo-oa fa a 6cw- -a pa-mit=y a idmc-.e the
I- ,.l clan=of en Moyer wader dao Wor$cl,coo3pomatio AeL
[uadczzaad that a Dopy of thin car.cmua may be for�.n+•da.d to the Dopenmco¢vrIn6u:ri c!ncolwsYj Offioe cf Gaa+�+oco ror t6.
�`�'o"e�^eif etioa and dLt L-ilta•e to LC=M toveraSe t>adc",lion 25 A.of).iOL 152 Qa lod to the inPoz�ioo of c-=iaal pe=liie
coau:.i:ta or a fioc or Up to s 1}00.00 azid'or of up to Doc y-....-d c vu PCO-16a is ttx form ora stop Wort;Or•dc and a
fl=of 51 DO.00 a d_y apjJ351 me
For only
perMjt NumbC7 _
Sipatuyc f-Lic sc: Pcrmitt�r_ ' > I 1 4t
SECTION 8.-CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
grRe"°usereotrrTmave'r[erGortr.ctot: � Not Applicable ❑
Company Name Registration Num er - --
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION'1NSURANCE--AFFIDAVtT'(M.G L.c.152;§f25CM)
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
r
SECTION 5-DESCRIPTION-OP PROPOSED WORK(check'aliapplicabie)
New House ❑ Addition ❑: Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[0]
Brief Description of Proposed
Work: Ps rht: 'k i,N Ili
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a_ €Neviotase°arxcor�actd�t�acl Lexcsttnc>r-lionsina- compfettthen[la�ncritq:
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 Pdvate well City water Supply
SECTION 7a-:OWNER AUTHORIZATION=T0_BE COMPLETED WHEN
OWNERS AGENT OR CONT.RAGTOR APPLIES FOR.BUILDING PERMIT
1 as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative ork authorized by this building permit application.
Signature of Owner Date
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 and r the pains and penalties of perjury.
JIM r
Print Name
f f
ignat a of Owner/Agen DatA
c
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
Side L:' R' L:l R:'
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?
N0 0 DONT KNOW 0 YES 0
i
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 Page; and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q YES Q
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 0 NO Q
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 I;
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 Q r NO I;
IF YES,then a Northampton Storm Water Management Permit PPermit from the DPW is required.
w .
e
City of Northampton t
1.
Building Department
212 Main Street se er ti
Room 100
Northampton; MA 01060 w�S s o pct raf PCair fi
phone 413-587-1240 Fax 413-587-1272 Pt� stfiat�s ,y & _�` z
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: Thts section"to be comp b
ieted yof#ice
„1 ,�>r'1lt"�f�
vi 10 Zone Oyerla Distrrct
Elie St Dlst tct CB D�strici
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
N me(Print Current Mai'
` Telephone
Signature
2.2 Authorized Agent: OCT 2 4
I
Name(Print) Current Mailing Ad - --
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed b permit applicant 1. Building (a)Building Permit Fee � Z,� 00
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building.Permit Fee
GCS
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This,,Section For Official Use Only
Date
Building Permit Number. Issued:
Signature: '
Building Commissionerlinspectorof Buildings Date
28 PENCASAL DR BP-2006-0456
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-286 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildinq
Category: BUILDING PERMIT
Permit# BP-2006-0456
Project# JS-2006-0678
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10715.76 Owner: VENNE THOMAS
Zoning URA Applicant: VENNE THOMAS
AT. 28 PENCASAL DR
Applicant Address: Phone: Insurance:
28 PENCASAL DR
FLORENCEMA01062 ISSUED ON.1013112005 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 Signature:
FeeType: Date Paid: Amount:
Building 10/31/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo