34-036 (8) 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 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 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 �°a�,� ,I-r c 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 G 3L07/03
Address of work
location SIP CHAPEL S• 01 oGO N'cDP,T-f4AMPIItJ MA
r
9 8 61f1) of a I I I p n I I
z _�A - 6 �ilasaarhnsctts ' —
ins I�EP;tRT?.f1? T Of' BUILDING INSPECTIONS
212 Main Street ' Municipal Buildimp `
N'Orthampton, Mass. 01060
wORICER'S COMPENSATION INSURANCE AFFMAN"IT
i,
(etc ,>_�r rFrnlitt.:�)
with a, principal place or businesslresidence �it:
-- ------- ------ - - - (phone:-)
do hereby ccrtiiy 1lndcr the pains aad peaattles oi,perjury, that_
I ain an employer providing the :oll��-,'.'In; �,:�1rr,ers compensthun cove,a�c for Iny
employees working on t tis job.
(Insttran� Coi���try) ( ci. ,NucnExr) (E pir tion Datc)
O I arh a sole prou"Ictor, c,-)n:racto; ur homeowner (Circle one) and leave 'tured
the contractors listed below wl:o have the follovv:n, workers col IluenSaLion )olic�.es:
---- -------------
(Manic of Contractor) �Insunnc Conu�a.r„Polio NtunEcr) (Esp:ratio�r Datc)
(Name of contf2CIOr) IILSU 3It�C COI'L /POIiC� Mm-Ay--r) (Exulr-,.tlon mate)
(Name of Contactor) 1n�i aII� Cot��:::rr,}ir'�I,c; Nuinf._r) x;. ..�: :- Datc)
(Name of Contractor) tIns2:r�ic.� Cote, -};rl'oLicy Numbs) (I�xl,:..a,o:i Date)
(r.ttadz�d!it:mal r!:;et;fr:crc:v: Cn i�.:bxic!:I:CK 1',.:111'. (nur.tt;
�_ ) I illlh a OIC prOi)r1 :Ji �'.1!Q h;iVC [10 O11C ''.t,'UT- Ilia for (I1e.
�� dill a
110I11C oAVnC: I)C[ICr1?11n tdl tilt ',vOi .....S .lj.
NOTE:p!c_ac lc atruc 11taL s' is't �t; Ia}''r„:.^� c':,Yt cr ir. :i«c;!i ,C'
riot cnccc than ittrne units in t�iidt t x fk,::»>•.tiT_r real cK cxt t1:E _
. :,is apputcr r�there o cc n t�c rs�ll y cc,:r.c rr':o h
capfoycs un cr Qr_w06c cis r:----;nticu :(GETS"�'t{S)l,ar,'ii�:-:i 6y n Fort fcr c tl,�
Icgxl ctatut of an ar,�Ioyor and r t::o LL'vi n'Y C xnjxr:.ti t Ac_
I undcnixnd thiL copy oC th:,ctat<:rnil r-:ay bo jxu nr�iocl to ttn P--j—tn—t of l,"it;rich A �6: if OfIi—of N!—.—for il»
coverage verification and tent flilurc to!,zUfc cUVCrng-,uz r ,icn 25A of MCH,152 can Ic-d to thn irnpositia-of c ;i: l pc11111:ci
conliatutg of a fine of up to S l-�CK oo a:YV r i ltriu nzk;u of up to crx.}t n j civil[xMltics in dx Cc r n of n Si'-')LL'c k 0—."-A a
ftaa of 5100.00 a day agtiin A¢c-
F,dq utzzrscsl u c«,fy
Pcrmit NtLmL-r
mature of Liccnscc l crnuttce
SEGTI b,Wa CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
I Signature Telephone
..
e e e m r. uemen Cqn r c r Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
i
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.
s Signed Affidavit Attached Yes....... ❑ No...... ❑
panic O,PVffewf iffi- on=
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 buildinp- 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 vrbr ° I° IC-
SECTIONf5 4fDESG_RIPTIONOFePROPOSED".WORK" check all'a licable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding Qp Other [ ]
Brief Des f Proposed Work: I M� ( J I L it') h)
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative o Renovating unfinished basement Yes No
Plans Attached Roll❑- Sheet❑
6al`f ` a h "se"a""d o atlil it-ionto> eXistingFiouin ; c'ornp"Ietethefotl,ow� ;
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 O.WNER'AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS"'AGENN_T.,,,", *CTOR'APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize __ _to act on
my behalf, in all matters relative tI-rwork 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 under the pains and penalties of perjury.
Print Name
Signature f Owner/A en-4y- 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:
City of Northampton S atus
Building Department Curb"Cuf°�D
212 Main Street Se er/ e
-
Room 100 Wa rIW t a
Northampton, MA 01060 T �Setsrrt c. �
phone 413-587-1240 Fax 413-587.1272 Pao /Site P n
Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
Address:
This section to be completed* ,office
1.1 Property
64 CIIA E I- Map Lot �Unrt
0(060 �OP-Tt-►1� Zone Overlay Drstrtct
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Go ►'j mpt21 C C-H A,PE71 sr
Name(Print) C.-,rent Address.
OIC)GO-__—Ncrr+PrMlo� -Mfg
Telephone
Signatu --
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
I SECTION 3'- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only — —
comp(eted by permit applicant_
1. Building (a) Building Permit Fee
-------- / ---------
2. Electrical I I (b) tirnated Total Cost of
Construction from (6)
3. Plumbing , ' l Building Permit Fee
i
1. Mechanical (HVAC)
5. Fire Protection — L —
6. Total = (1 + 2 + 3 + 4 + 5) r Check (;u!nber
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2003-0742
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0742
Project# JS-2003-1203
Est.Cost:$10000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin Homeowner as Contractor
Lot Size(sg.ft.): 24393.60 Owner: MARIC LORAN&AJIA
Zoning.URB Applicant: MARIC GORAN & AJIA
AT: 64 CHAPEL ST
Applicant Address: Phone: Insurance:
64 CHAPEL ST (413) 582-0133 O
NORTHAMPTONMA01060 ISSUED ON:317103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VINYL 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 Sisnature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 3/7/03 0:00:00 788 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo