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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street * Municipal Building
Northampton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction supc.�. " sor. 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-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 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, � �,, ,,;��, � .J� understand the above.
(Home owner/residents 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
4�tV.H PTO �
0 °a (LIt1T of 'Na tllaiitptnn �I =
9 - 6 �3iaaaxchusrtta ^I
m DEPARTMENT OF BUILDDIG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S C0117PENSA'MN INSURANCE NFFMAVIT
1,
-- - (]i�nserJternlittce)
with a principal place of btusiness/residence at�
-
---- (strcet/city/sta.t:.�rsp)
do hereby certify, un(ler the pains and penalties 01 perjury, ttim'.
( ) I am an employer providing the followIM-, compensation coverage [or my
employees working on this job:
(Insl=c comp-n,) -- - --- (Pe!-;c,Number) ---- (Expir;:tkn Date) -
O I am a sole proprietor, general contractor or homeowner (c rcle one) and Have hired
the contractors listed below who have the fok wing workers compensa ion policies:
(Name of Con(actor) (Lnsur ncc Co ill oany,'Poti(--f Nwnbcr) (Expiration Date)
(Name of Contractor) (7-nsm-,mcc Conmaiw[Policy Number) (lap;r,tio❑Date)
(Name of Contractor) (Ins taco Comt�anylPoGcy Nuivber) (1=s,;irn_,D Date)
------------------------
(Name of Contractor) (IIUZ:I ulce Com;allyll'olicy Number) (E :pi.!:ion Date)
(atiae,t id!iticcsl s.':,�t irr.cre:s,r:_n ��ri-ix!c i.c•c,r:i_ia:�staiu::��::ell r<:->c:t;:•)
i l
O I tun
it sole proprietor anti have no one for me.
home ownel- performing all the ,vor'l- •;ys-If.
N0,11::plc�ac tY ntra;c tha:,ti?:ilc lxt xo ti;r_n +.n�cr., toy ;s to c:> 'ain` Cr t;')atr u" ^
not I cc c th_n thrro units in ;he k ter,zrzr rcaid:a e<at L� zpfurt:c:r1 thacto tic nc<Ec rsally arm:
--lrployca u_xicr the workrea m.;, :stied Act(GL152,sa 1(5)),r{yl:_zicn by e hotneo«:ra for a Lce2se c<Pero:;;n.-v c.-: n e C,tc
Itsal rt."of an cmployx under t!-,o Worker'.com;x tion Act
I understand tLxt a copy of this ctzt--t rt ay bo fcn—U�iod to tbo D<j o t—xt of Ind,uurid Anoe,. tf Ofr—of tug,—s for tlw
eovcnge vaifieadoo and that failure to c<utre covrraso ur-L-x section 25A of NiGI,152 can lad to tho imposition of C=,3_I pcc aloes
Consisting of a fttx of up to S 1.500.00 ar,:Vor of up to on-}t-r a.•�I civil perultia in do fcmn of a Step Werir.ot�-ar.d a
frrto 0(5 100,00 a dsy agunst rrr_
For dcpi trrrld�l u.o only
Permit Ntimtxs
Map Lot
r Signatum of Lio=scc/Pcrniittcc �
SECTION 8 -:CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9 Registered Nomelmp`rovemeri Contractors.a._ „y ,, , ,,,'; y Not Applicable ❑
Company Narne 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...... ❑
191: I.om e ,w.ner E EW15fio
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 fe-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�ancl State of Massachusetts General Laws Annotated.
Homeowner Signature 1�ti1w
SECTION 5-bESCRIPTION OF PROPOSED WORK(check all,applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ] Decks [ ] / di g Other [ ]
c
Brief Description of Proposed Wor _ -�rc'VV\.
°w
Alteration of existing bedroom __.__Yes ____ No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement _ Yes _ No
Plans Attached Roll o - Sheet ❑
5a. if"New'hous"e arid:or 'a'ddition to existing h'ousin , complete``the f011oWing_
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. — _ Dimin bris _-
a :
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
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
1 __, as Owner of the subject property
hereby authorize _ _to ac; on
my bef ,�-If, in all matters relative to work authorized by this building permit application.
Signature_ of Owner Date _
as Owner/Authorized Agent
hereby ,eclare that the statements and information on the foregoing application are true and accurate, to the best of my
knowle�:ge and belief.
Signed :nder the pains and penalties of perjury.
Print N--^e ---- - —
-- — ---------------
Signatu— of Owner/Agent Date
N ,
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 1 _ 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 ✓ t'ON'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 Status of-Permrt=
Building Department CurUC-6 %gDr�veway per• i ,. `;
212 Main Street Sewer/SeptrcA arlab � " `
Room 100 Water/Well Ava 1�ab li_
Northampton, MA 01060 Two Sets of Sttr cturah'Plans_
phone 413-587 1240 Fax 413 58? 12 72 Plot%Site Plans -n WN
� _ '°
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section to be completed by office
I
Pl1ap Lot Unit
„e VN C C _ Zone Overlay District
Elm St. District CB District _
SECTION 2 - PROPERTY'OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
-- - � b o
Name fI'rint) C.. Ent r^, � Ad s5
igi—i,re
2.2 Authorized Agent_
Nanic (Piint) r Va �
I
i
SignT=' r
SECTION 3 • ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Only
completed by�ermit applicant
Building (a) Building Permit Fee
_ �b` rued Total Cost of
_ construction from 6
3. Plumbin
g � 1 Building Permit Fee
4 Mechanic (HV��r_-- -- __-_
F--- - --
5- Fire Protection
6 Total = (] + 2 + 3 Number _ — --
This S ction For Official Use Only
Building Permit Number: Date Issued:—. _ — —
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-0041
APPLICANT/CONTACT PERSON WILSON DEBORAH B
ADDRESS/PHONE 64 WEST FARMS RD
PROPERTY LOCATION 64 WEST FARMS RD
MAP 35 PARCEL 022 001 ZONE SR
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: REPLACE 15 X 30 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
TH�FOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF TION PRESENTED:
pped 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:E;lm ,tr eet Co ssion Signature of Building Offici 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.
BP-2004-0041
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0041
Project# IS-2004-0064
Est. Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.fo: 38507.04 Owner: WILSON DEBORAH B
Zoning: SR Applicant: WILSON DEBORAH B
AT. 64 WEST FARMS RD
Applicant Address: Phone: Insurance:
64 WEST FARMS RD
FLORENCEMA01062 ISSUED ON.7110103 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE 15 X 30 SHED
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• Receipt No: Date Paid: Check No: Amount:
Building 7/10/03 0:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo