34-031 (6) A A
HOME OWNER EXEMPTION ACKNOW*L:EDGEMENT
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, 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
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DEPARTMENT OF BUILDrNG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMPENSATION INSURANCE + ' AVIT
-ham -
(IicenserJpermittee}
with a principal place of business/residence av
61 -7-1 c L C Sf... (phone#) d-/
(streetici ty/stalr/zip)
do hereby certify, under the pains and penalties of pegury, that:
( ) I am an employer providing the following worker's compensation coverage for my
employees working on this job:
(Insurance Company) (Polio Number) (Expiration Daze)
( ) I am a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below who have the following worker's compensation policies:
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
,,
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (insurance Company/Policy Number) (Expiration Date)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date)
(aaach additioail shcct ifneccsssry to inchidc information p<z i tng to ell ooatmaors)
. I am a sole proprietor and have no one workdng for me.
( ) I am a home owner performing all the work myself.
NOTE:please be aware that while hOOICOW1Kt3 who employ p';'or=to do mar�cornrruc:loa or repair work on a dwelling of
not more than thnx units in winch the homoowacr mid=or on the pest x s appurtzm tbacto an:not wally oc-as idcrcd to be
employers 11I]dCf the worker's compensation Act(GL152,ss 1(5)),applicat;e n by n homcowna for a license cc permit may evidence the
legal ctanrs of an employer under the Workcez Compmsaiion AcL
I understand that a copy of this sEatemcat may be fb wnrd d to tbo Dcpertmcat of Induatrinl Accidrnty offioe of In:x-for the
eovczx verification and that failure to&4:c=coverage under seetioa 25A of MOL 152 can lead to tho imposition of criminal penalties
consisting of a fine'of up to S 1,500.00 andloe imprisoamalt of yip to one year and civil pmaltics in the form of a Stop Work Ord-and a
film of 5100.00 a day against Mr-
For dgnut-� tsso only
permit Number
Iviap# ___ Lot
:r Si of Licrosedpermiucc e
4
SECTION 8-CONSTRUCTION SERVICES'
8.1 Licensed Construction Supervisor: 'jam- f� l Not Applicable ❑
Name of License Holder :_ ' / S / r ,! 6
License Number
4 T-) C sr G L - �,C��c 7A
Address Expiration Date
Signature v Telephone
�Reg(st�retl F�omelmnr•�vement�'�,ontt•actor �� �a,��, _ a:. i,� .,.��...����L.. ._�. ..:� Not Applicable ❑
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.
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 fob 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=°IAE '_IPTION"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: t`T�?/US -��rrY S�,vfL t rlf—. 'I-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
dGr
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
sa If°Newhouse° ��tid�or��tiditfon°to�exis"tang, housin comple#e�the followinir:
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? yL
d. Proposed Square footage of new construction. �;�4D + y�6`l Dimensions
e. Number of stories? e�-
f. Method of heating? 11 (r l Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. 47/C Mascheck Energy Compliance form attached? y CS
h. Type of construction I—
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 :s s
k. Will building conform to the Building and Zoning regulations? Yes 1C No .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED' WHEN
OWNRS,AGENT OR CQN7aACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent
hereby declare that e statements and information on the foregoing application are true and accurate, to the best of my
knowledge and beli f.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agegi 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 I �r �,i /12—S
Setbacks Front t7 '/'b
Side L: R: L: R: a
Rearfl
Building Height J
Bldg. Square Footage % j y 0 C S
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill: N
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: 11 bul U
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book `� �S Page d-3 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 Commis n�
Needs to be obtained Obtained � , Date Issued:_�,2 c)nl
C. Do any signs exist on the property? YES NO X
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:
ity',f'Northampton S >'
Building Department
212`Main Street
Room 100 a
1.`�`,✓ ,`
Northampton, MA 01060` _
- phone 413,587-1240 Fax 413.587-1272 Pa 'STV`P
Other�Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION 3 q 0?1"
This section.to be completed by office
1.1 Property Address:
Map LotUt
Zone Oirerlay Distr►ct :a y,
Elm St. District CB District
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of�Record- J
4f 14 j 1 Y !�(�t r 1 cI f•t S � G `1�` `// �'®.�7� t:. G GG
Narrle rint) Cur t Mailin Address:
L-ur�{'�.'G -
Z'7 Telephone�-- i
Signat re J "'� 0
2.2 uthorized Agent:
Name(Print) J i Current Mailing Address:
Signat re Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by ermit applicant
1. Building d (a) Building Permit Fee
2. Electrical r i (b) Estimated Total Cost of
J Construction from 6
3. Plumbing Building Permit Fee
Li v
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (l + 2 + 3 + 4 + 5) Check Number
T is Section For Official Use Only
Building Permit Number` Date Issued: -
Signature:
Building Commissioner/Inspector of Buildings Date
329 TURKEY HILL RD-LOT Al BP-2004-0646
GIS#: COMMONWEALTH OF MASSACHUSETTS
MaR.Block: 34-031 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Cateizory: BUILDING PERMIT
Permit# BP-2004-0646
Project# JS-2004-0926
Est. Cost: $155000.00
Fee: $920.60 PERMISSION IS HEREBY GRANTED TO:
Const. Class: 5B Contractor: License:
Use Group: R4 JAMES HARRITY 052260
Lot Size(sq. ft.): Owner: EQUITY BUILDERS REALTY TRUST
zoning:RRIWP Applicant. JAMES HARRM
AT. 329 TURKEY HILL RD - LOT Al
Applicant Address: Phone: Insurance:
77 MAPLE ST (413) 585-8025
FLORENCEMA01062 ISSUED ON:12119103 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT SFH MODULAR W/ATT
GARAGE/DECK
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. j�[� Rough: House# Foundation: QK /9-,? 7-e3
Driveway Final:
Final:; - Final:,Z—3 y
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation: ,c,�
Final: Smoke: Final:0 k 2-1V-0y
A,
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
J
Certificate of Occupancy
FeeType• Receipt No: Date Paid: Check No: Amount:
*90 DAYS TEMPORARY OCCUPANCY PENDING.DPW APPROVAL — EXPIRES 05/17/04
Building 12/19/03 0:00:00 2959 $920.60
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo