29-283 (2) 0 0
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
s
Northampton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 1083.4 to
act as 1-A's/her construction super: 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 baekfill),
sonotube holes (before your), 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
a E (yrf7�3 of �.�t7ri ltal)t}�falt _ _
Rf E 3�.3ait cflrtccIIZ'
p DEPARTME14? OP BUILDfNC INSPECTIOA'S
212 Main Strcet Nfunicipal Building
Northampton, Mass. 01060
f `VOR1CCIZ'S COYQ'ENSATION CgSURANC-AF=- AVIT
i
i
(liccnsxJperinitfcc) _ - --
v"ith a plirtcipal place of business/residence zt:
�X& o A) At 71
i _ ( c�ty/siatc/ri p)
do hereby certify, under the.pz-.uu and penalties of perJury; :hat
(141, am an employer providing the iollo.vine tvorkCr s comaens:dor. cove age Lor u )
employees working on tliis job:
aand---n= Company) (Polio:Nu-b='r) -- :-pirvon DzL.)
O I acn a sole propnetor, general contramor or homeowner (cucie one) and have hired
the conicraciors listed below wbo have the f011oivi9Q worker s co n_ enszdon policies:
('NaMC, Oi CO2MIC10r) (Insurance Coinowny/t ouC i ?�rLLLTt�C') �_iJ1,'JOQn I�1lC)
(N>nc of Contraor) (1rls.tranec Coman`•iPouc \uncrr) (E�mirz6on Dale)
(Name of Connaaor) (Insurance Compan}-fPol;q- Numb -r) (Expirtioo Datc)
(Name of Contractor) Gnntfanc-- Company/Policy Number) (Exp mtion Datc)-
(na.ar� 6ca,if ncccu_-p to¢tcuc'�iafo Mt Moo Pa-ta..inins to a1,1
{ ) I am a sole propnetor and bave no one world.ng for me.
( ) I am..a home owner performing all the work myself.
NOTE:Plesc be et.;rt th,.�tJe bemeo..vm"I'cmPloy P-=ow to di c• -• =,—z=,oc or repair-Or-k oo L d..cn_F,of
ant most th:o tbzcw tetra in tc$ic:h the bomoowo raid=or oo the Crvuors sapartca=thc-ex wz ooc Coccnp o�sid=oi to be
cixploycs undo the--cj d 0n=p---,:ca Act(GLt 52-=l(S)) zpplintion'try a bomcoamcr for c bc=r-x or permit r>_y c idcooc trc
Icgs-1 etssu of an erployx under dto WocSC ,Co.*.o Gi AeL -
I uadcstaad Iba a Dopy of this mr_=may be f ded to the Dopuvaco¢of IO&a ial A. dca&OM-or[r>rur•o fx the
oovcxcc vcriGc!oa and th:1 U*=-c to i-oc=)covey&1-adcr soclioa 25A of 1.(GL 152 can Iad to tbo izrro oo of c mi-1 K-,W=
coals ims or a free or up to s 1500.00 andicc oC uP to ovc year end c�i1 poz.t.j.t.form of a Stop Work Orde and a
rruo oCS100.00.d_y epinst me
-
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SrGn�zturr of Lic�tsccJPcr�tttucc e __ .) F
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SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder, ° Q
License Number
Address
Expiration Date
Signature Telephone
L -yip
9= 3e stereclom J)ernenont Not Applicable ❑
mar
Company Name e7 Registration Number
Address �V71�� Expiration Date
/V O Yc: tO P4) Telephone d O d
SECTION 10-WORKERS'COMPENSATION INSURANCEx1FFIDAY1 (M.G L.c.152,-,§25C(6))
Workers Compensation Insurance affidavitpiust be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buildi 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 buildine 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement dows Alteration(s) F--] Roofing E7 Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding Other[O]
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
s�a�l� iEki`oaS��'anc��"or: '�i�io' tcc�xis�nt�ous�:� ;�omt"' �e , o'Iac�:
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-OWNERAUTHORIZATION-TO BE`COMPLETED°WHEN
OWNERS,AGENT OR:'C`ONTRACTOIt APPLIES.FOR"BUILDING;PERMIT
N SI�C,�j,y,�/(� as Owner of the subject
property
hereby authorize
to a on my behalf,in all matters relativeto work authoriz by this building permit application.
—^ —°
Signature of Owner Date y A10
I,
AJ " / as 0*plr/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.
z�''Z,a /'
Print Name
.E dL l /"/I L/ c�b
Signature of.Qwftr/Agent Date
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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
Rear
Building Height
Bldg. Square Footage -----7 %
Open Space Footage % F---7
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Vorianoe/Fimdi ng ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, dote issuad:
IF YES: Was the permit recorded at the Registry of Deeds?
'
NO 0 DON7KNOW 0 YES
IF YES: enter Book and/or Document#
'
B. Does the site contain abrook, body uf water orwetlands? NO 0 DON 7KNOV 0 YES 0
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained ��' Obtained v�� 8mta �sumd'
v~~� �~� ' ' .
C. Do any signs exist on the property �� ��� Y[5 �~� NO «��
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 0
IF YES, describe size, type and location:
E Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre oris it part nfo common plan
that will disturb over 1acre? YEG ���% NO ���)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton Staot _
Budding Department
' 212 Main Street '
Room 100 kf
J Northampton, MA 01060 , u
I hone 413-T-1240 Fax 413-587-1272
aS
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Tftts�seo61n to wiedffip, ed by affce
1.1 PropertVAddress , h
R t 1� k
J
SECTION 2-`PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address- >
y Telephone
Signature � b
2.2 Authorized Agent: ,1/
•lz W i �.. 13,mx)1 p9", /J gel 4,<> y' �ycj� �Rho Td� kA-
Name
(Print) ? Current Mailing Address:
Signatu Telephone
SECTION 3-ESTIMATED CONSTRU' ION.:COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building �---'- p)pftilding.Permit fee
2. Electrical 44 Estimated Total Costof'
Construction ftam:6
3. Plumbing Building Permit Fee-
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) jw7J a 0 lCheck Number
This:Section For`Official Use Onl
--Date
Building Permit Number. Issued:
Signature:
Building Commissioner/inspector of Buildings Date
0
4 PENCASAL DR BP-2007-0546
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-283 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-2007-0546
Project# JS-2007-000792
Est. Cost: $7100.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq. ft.): 12806.64 Owner: SLOCOMBE DONNA L
Zoning:URA/WSP Applicant: B & R Siding
- AT: 4 PENCASAL DR
Applicant Address: Phone: Insurance:
781 Bridge Rd. (413) 586-4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:1111412006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS & SIDING
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 11/14/2006 0:00:00 $25.0020641
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo