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DEPARTMENT OF BUILDITjG 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 has/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 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
1, 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
� _ � (1�xftt z�f �1crz-tl��-tl�t}�fcltt
6 aseacli[If ctle ' —
a� DEPllRTMENT 01' EUILDT?�G INSPECTIONS
212 Main Street ' &funicipnl Building
NTorth amp toll, 2fass. 01060 0,
WORKER'S COiYTENI SATION INSURANCE AFFEDAVIT
(lic�rs°r_�'r�rtniltcc) � --
v:rith a principal place of business/residenc�c 1:
do Hereby Cel—LlI}t. Un:'cl tllc 1x:111s and pCil 1tiCS 01
( ) I am an employer providing the ollo`.v;r!t_ ".;orr_crs colnnensation coves ,e or Iny
employees working on this job:
(Lnsl.=C: Conp'- ') clic;Nt.mber) (rx:pirrtlon Date) -
j 1 any a stile proprietor, gtta-ra l CIF cle one) and 'gave hired
the contractors listed bei0w ,v!;o lI the oll ; g ,,'ori;ers co pers on
(- amc of Contractor) -
CL c Come 1usnr) �ic- Dat )
(Name of Con tla o-) -- (7nsur rc Co7I:D_rn7Pc!icy Nun,b--r) Date)
-- — --------
'ame of Contractor) r:c Da1',-)
- (Name of Contractor) -- (InsZ ranc Cotnr ryI}'Policy Numt,��) (I:xni-::iar Dare)
i
1 "ct�I1 <. (}1C pfUl?IIC Ji <':I11 ill?VC PO oli lOr illc.
1 iIl �? 1:oI1?e C�,'l]C: pCi?C"II11I�^ al( t,, i
No'IT:plc�sc be atrazc tlt�:.ti•:IC f !r�Ott tt
t�•,.?:�^s�t�cl
nn(UKcc tlLn du1 cc uni s ir,fit{:;Gil taK]:;,::ti:-;•.tr rr-:c::z cx oc;::t.: ,_:._:a ��r:cr.-r1 LhcCC e:e n.:<eaXrally :J t\:
c�pioya.3 u_rry c' ttx tw;�,�:cc ix,r. <''.15�_.i 5
( t ( 1„.:r-_aac;;ty a hnta oat rr:`cr a Eca_,c ct
]csal ctztus of en amployx unu' t1.n Worker-CcX=, _-.anon:'_cL
I ttndc.-itaad tfzut i copy of t}v ctatct—i r_uy bo fak-�uc1 to tl»[Ytivt_z,czL of Iiv6istriJ Act&d &Cf acv of for Ul
oovcm&c vaifiealioc and th-t L-.durr-to!:CL,-,-mt n M ut 3:zceiM 25A of MGL 152 can Ic-d to tlx im-tibon o;r^1n_1 pctsl::a
cvmilting of a fur-of up to 51-SMoo and c r i^::ir,_vx t of up to cr.-y :.j coil pCMIGu in d c Ic nn Of a X-')`;vc Y.0-,-k',-.r 1
f r> oC S 100.00 a day iri-in:.t tn..
i=cy ciq;uvzrrtal u.c drily i
Permit NWJAX 7 --- -
SECTjON 8:-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Re°g�s" er°el brne m� ouem`ent�Co"�ntracto M, N Not Applicable ❑
-'L///✓d c0 Kf' �/�Oi�G-C �O �Q Gt O
Comp any Name
f Registration Number
/ /
Address Expiration Date
AA d/O S Y Telephone —57,Z
SECTION 10 YVORKERS' 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 job site will be required from time to time, during and upon
completion of the work far 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�DES PTkONOF3PROPOSED WORK checkall a licagble
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding W, Other [ ]
Brief Description of Proposed Work: 9r=,LA« Scd �C _}�, �;� (.� c-�(�L��c�c�rea� �..I-A-AL41 5
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a f New o�rse end sting h'o`using�OCmple�e e fo lwocn-orM 1;ion, exi
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 .
1- Septic Tank City Sewer Private well City water Supply
SECT ON 7 OYYNER AUTHORIZATION TO BE COMPLETED WHEN
QWNEkSAGENORCON TRACTOR!APPLI,ES FOR BUILDING PERMIT
I' 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
l '-��%��-- �--"� ►'�'� �/ , as Owner/ uthoriz_ed Agen
hereby declare that the statements and information on the foregoing application are true and accurate, to the es._..._ y
knowledge and belief.
Signed under the pains and penalties of perjury.
hf',
Print Name
Signature of OR r/A en 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:
� a
n" Tc;Ci f Northampton
�$ l �lipg Department
Ce
1 212 Main Street
100
Northampton, MA 01060 µ*
phoge,413-5�7-12 0 Fax 413-587-1272
rc�
APPL-ICA?ION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
N This section to be completed by office
1.1 Proaerty Address:
z�t�r"t�h"��:4�' � �"��?r$M�'•+���#5 r asd krh �r"� �'i' t
r r Map Cod C1n�t
4 K
EIfM St. D IStrICtB
SECTION 2-PROPERTY OWNERSHIPJAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address: 7 O 7
Telephone
Signature
2.2 Authorized Agent
—C7
Name(Print) Current Mailing Address:
Signs Telephone
SECTION 3-ESTIMATED CONSTRUCTION`COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)`'Building Permit.Fee,
2. Electrical (b);Estimated Total.Cost of
Construction from 6
3. Plumbing Building Permit Pee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2+ 3+4 + 5) Check Number
6v� � "— JO
This Section drrOffi!cial Use Onl
Building Permit Number: Date Issued:
=Signature. missioner/Inspector of Buildings Date
1 i
952 RYAN RD BP-2004-1171
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-055 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-2004-1171
Project# JS-2004-1771
Est. Cost: $12362.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sg. ft.): 15246.00 Owner: LAPAN LEO E&THERESA M
Zoning: SR Applicant. John Corbett
AT. 952 RYAN RD
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON.5124104 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL SIDING & REPLACEMENT WINDOWS
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 5/24/04 0:00:00 1902 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo