29-283 (9) 10
iI
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or hvo 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-=rear period shall not be considered a
home owner."
The building department for the City of Northampton wants 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
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
Ol Ut;ii _
(;<)MITT'' SA" I'W", 11'�-SIIIZ>>tNUI"' AFFIDAVIT
c�n!i;lo,�cc,, •,r,�i�l:-.us ��r �_'.i; icf�.
(I,.s.,,�..
1 _,,. .? ..,:i; r,;l� d! lCI7:1^�:C�C � .__. ..,J`,'�'Cl�: �•_. .� ,. _ :.,. _ ,i1rC:i:
�;o h v
(?� t.n:� r,C' .�. •_.._. i Llsu.��t_c. C'on.. ...� .�,, Nt:,,.._-) .Datc)
N L,;} Nate;
17,Cc)
tol i'a'
cr�,Io j-c: u:v;tr t}r.«r:) -
.�: .-.. ..:c
1<gal ctahrc of ctl c::y ��K un�cr tim lV cv4cr'c Co;njrari L:,ct Ad_
I u:xicnund th.t> ,p�of
co�'��gc vc ific�ii�a:'LtL[f�:;�:c to�ca!rc UVCin�vi i r xciic 25.A of�dC 1,152 can Iced to t!x:im;vsiva,o` -1 pct ell:u
Muting of a lira of u,to S 1"'().m aa."cY i :pris ,�-;,!of u,to c;: r.:.1 civil Ixzulticl in:1r 11Rin cl
fi m of S l(10.00 a dry �:�.in.t tn-_
_ !at Fct�Sq;+itnr tnJ u�c��nt}
1 " Pcrtnit TllunL
7 sic fu cc of I,tccn_cccrtuttt � F
- ^ A# '
SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable [:1
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE 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.
~ �
The current exemption for''homuuvuoo"was extended to include{}wner-o [one(|) ortwm(2)families
and to allow such homeowner to engage an individual for hire who does not,poxxoxx a license,
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 thc Building Official. that he/she shall be
responsible for all such work performed under the buildiniz permit.
As acting Construction Superviso your presence nn the job site will bu required from time to time, during and upon
completion of the work Kz which this permit is issued.
Also bo advised that with reference toChapter 152(Workers' Compensation) and Chapter 153 (Liability oF Employers m
Employees Dzc i^judm uo/.uu\1ix- io ""xxu^-' ro| Laws A.motutcd, you may be liable fbrpuroon(o)
you hire to pur[bnn work for You under this permit.
The undnnionod^hnmeowoc/' rnrtiGoo and usmmcSnmpondbi|ity for compliance with the State Building Code,City of
Northampton Ordinances, State and Local Z i Laws and, S/ [M,, h tts General Lvws Annotated.
Homeowner Signature —
w �
,p •
SECTION 5-'DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work�U� ��L�1 s tLC Via ' �- --- 14,Y 7 —
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll U - Sheet 0
sa`If New Fious'e and or`atltlition"to"`existing"ti`ousin complete',Ahe b11JdWkiji :
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 -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS`AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize `�� �- "'�' _ to act on
my be If, in all matters relative tork authoriz d by this building permit applic 'ion.
Signature of Owner Date
as Owner/.Authorized Agent
hereby declare that the statements and j ormation on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print N'PrTle l J
Signature of Owner/Agent Dat
M ry
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 L/
_ 7
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location)
A. Hasa 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 I�
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 �I 110, Of MrtHampton SMusf—
` —Bulld" Department CurbCp"SID
212 Main Street Sewer�Se -
w� Room 100 Water/VJe va
Northampton, MA 01060 7waSetso s�
pf oije 413-587-1240; Fax 413-587-1272 PI t%SItePla .'
OtherSpeCtfy,;
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Proper ddr ss: This section to be completed by office
Map Lot , Unit
-- +,
Zone n e
►G V'�� !_ -_Overlay District g +s
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: (� i
Na e(thi—)
,a / Current Ma n,Address: —
y Telephone
Signature + �a
2.2 Authorized A ent:
Na (Print) Current Mailing Address:
z
ate: U CC tY)
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be �— Official Use Only
nlp � 4�
'"if "nii—ni
m ri
1. Building ` (a) Building Permit Fee
2. Elecirical (b) stirnated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
�e
4. Mechanical (HVAC)
i
5. Fire Protection
6. Total = 0 + 2 + 3 + 4 + 5) f i Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2003-1135
APPLICANT/CONTACT PERSON SLOCOMBE DONNA L
ADDRESS/PHONE 4 PENCASAL DR
PROPERTY LOCATION 4 PENCASAL D�N ,5p
MAP 29 PARCEL 283 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: ERECT 10 X 12 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included• -
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FO WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Co n
Signature of Building Official Date
Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
4 PENCASAL DR BP-2003-1135
G1S#: COMMONWEALTH OF MASSACHUSETTS
Mapjlffock: 29-283 CITY OF NORTHAMPTON
Lot!-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-1135
Project# IS-2003-1795
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use GroM. Homeowner as Contractor
Lot Size(sg.ft.): 12806.64 Owner: SLOCOMBE DONNA L
Zoning:URA/WSP Agglicarr: SLQW-15E DONNA L
AT: 4 PENCASAL DR
Applicant Address: Phone: Insurance:
4 PENCASAL DR
FLORENCEMA01062 ISSUED ON.6116103 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 10 X 12 SHED
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing 0 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: k ?- � "�3
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA OF
ANY OF ITS RULES AND REGULATIONS..
/ / J
Certificate of Occupant ,�i� � Shmature•
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 6/16/03 0:00:00 5227 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo