35-043 (4) 'ttU►MPT
Oq_ O
of Nort4anipton z
�A35A[1t11Attt5 -
rs DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supi�, ,,iSor. 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 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
� � 6 hixsancflusrtis '
i
k.
z m DEPARTMENT OF BUILDING INSPECTIONS
212 Maui Street ' Municipal Building
Northampton, Mass. 010G0 ' a
WORKER'S COMTENSATION 1NSURANCE &FFI DAVIT
%with a principal place. of busiressir :;idence
(phonci=�
d0 hereby CCJ—LLJ . un:c1" t11c' h%:i15 !'.ilc Pcil ltic'; Oi 1)f'.f] HN, '..hi!'-
I am an employer provitiI the follo'.v;n� '•:c>rr_er'S cornpcnsation covert: c or Iny
employees working, on this job:
J=a=cz Corapatry) c c;N, lber)
j I and a sole proprietor, general con�=c`cr h02le01,Vicer (cLrcle one) and leave, =td
con c'ictOrS listed btio 'i ;'^0 ilr the cs:
(`amt of'Cwu aor) (InS,'Tanc l GIPn-::TF 1 G!IC T1 LrIl r) T'', •+.11on Datc)
(N=c of Contn'c,or) -- Oils-jmncc Co ? _awPo!ic; Nt r err; (F:c do Daie)
(Name of Contractor) (In;arsle� (-o;��;.n}'Ifolle:NtlJnlxr) =x;,:7:z a Data)
(Name of Cont-aciGr) — (Inalmlic:, Col m=. PoLicy Numb-r) (I::ri :tio: Dale)
( 1 ium a sole 1?1 Ul?:1C:Ji cii:1 ili?'. i?O OIIC ii I" lii ' �Oi ii?C.
c
*:OT't::p(casc t`c n�+•arc L:>:•.ti i]c txrr�:�«zrc-s�,-�c._�i,_,,,it_.���� :::���_:�nc�a.:_n:�.:m ct:c,�au« ......_�«cl!i::,:.
not umcc th_n(limo units in r= a-a:
1=ployca ury et ilv t c.4:e.c cc hortco«-rr`:or a l cu ct
legal aatua of an o=ployx under tt:o We icc.'z(:; im;-orr_.tion?cL
1 undc-xt. d thi i copy Ofd—cta[c:s•c,.ay bo fot—tud J to tlr.D-j-t—a of IndiUricJ MIL :f Off--of ic:=r.u>?_c for tlx
cove-agc vc;if c:a ion And t1Lt 1 il=to r_ c c01.---3n UZI -;s41:�.iM 2S.l of Mcn,152 can Icy to the im-'c'sifion c" cs
Oomuting oCa fur_of up to Sl„i00.CvJ a:t"JCx i:::;tr;vx�;,-:;:of::p to or,:}-�r.;.j evil,:_nsttia in yC?��njt cf n S!c-,1Vni C},'u�ar.:l
r-t c 015 10000 a day
For 6r-tll—e-'l uic uil y
5 7H it7 rC (7f I �CC17 T1iI+:'1 _T;1; `: I
SECTION 8' CONSTRUCTION SERVICES
8.1 Licensed Construction Su rvisor: Not Applicable ❑
Name of License Holder
( Lic nose N mber
Address Expir Date
Si ure Telephone
is
Ae" to ed brne mgr' vem Co"R ct r..: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 1NORKERSG0MPENSATI0N INSURANCE AFFIDAVIT(M G:L. e. 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...... ❑
-r
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 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
• y
SEC 11,69 D S&- FPw„TION1OFffPROPOSED WORK(check all applicable)
.. .,,: x
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding[[ ] Other [ )
Brief Description of Proposed Work:
Alteration of existing bedroom Yes o Adding new bedro Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll D - Sheet D
6a�1f�� lou"�> n�i��atldi=Pion`to�ex�sting=fiousingcomplete the�fol=lowln�
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 7��OlNNE 14 b, ORIZATION TO,BE COMPLETED WHEN
OWNEkSAGEIT�OR CO NTRACTOR'APPL'IES FORBUILD'ING PERMIT
_ as Owner of the subject property
hereby uthorize
y ��� to ac,. or.
my behh If in all matter e to work authorized by this building permit application.
Signature of Owner Date
as Owner/.Authorized Agent
hereby declaJbief.he statements an informa ion on the foregoing application are true and accurate, to the best of my
knowledge a
Signed under the pains and pe es of erjury.
j m
V a of Owner/Agent 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 DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT 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:
s
r Cit,( of Northampton
�IMing Department
-� 12 Main Street
n'D Room 100 .
N pton, MA 01060 a� �
phone 41 -58 -1240 Fax 413-587-1272 ` '
t
A is ,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 ProDertv Address: This section to be completed by office
Map tat A Unrt
zLQ_
.Zone ;;O�erlay District ,
2
,,,FJm St.D�strtct �. : CB D�sMct
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZED-AGENT
2.1 Owner of Record: f,
el
Name(Print) Current Mailing Address:
'*_Y� ( Telephone
Signature
2.2 Authorized A ent:
Name r t) Current Mailing Address:
Sign re / Telephone
S ON 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
corppjeted by ermit applicant
1. Building �/ (a)Building`Permit fee
(/
2. Electrical (b)Estimated,Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total = (1 + 2+ 3+4+ 5) Check Number
This Section For'Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
I It
971 RYAN RD BP-2004-1246
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-043 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-2004-1246
Project# JS-2004-1888
Est.Cost: $1500.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: James Roberts 117154
Lot Size(sg. ft.): 19994.04 Owner: CUSTEAU GERARD A&DOROTHY R
Zoning: SR Applicant: James Roberts
AT: 971 RYAN RD
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON.618104 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 6/8/04 0:00:00 2140 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo