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DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building S ,
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as 1-1is/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 baekfill),
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
0
DEPIaTMENIT OF BUILDD�G INSpECTIONS
222 Main Street * Municipal Building
Northampton, 2fass. 01060
WORICER'S CONITEN'SATION INSURANCE /-FFMAVI.T
(lien
%vitla a principal placc, of buslincssJrn cnc-,
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ari-c-lapioyel- PFO",, , t� L my
tmploycts on t 1 jjcb:
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I am a sole proulletor, gentra i 'nCT--il,e0"v= (Cl cle Occ) and
0 F k e I .0 j S 0 L7
contractors fiste�d bei-ow -;,tno 11,av�-, the?
(Naric of Connac,,o.,-) (11L-um.2c: (E 7-, i,:l n Date)
(1,,Tame of Coati-actor) jC_', N Tlllljj:
(Name of Contractor) Date)
ani a 'sole propn,CCUi a ld hav" 110 '011,3 oFkij""-, fo,- nne.
I? home
NOTE:',)I=SZ be awalc U-1, Cr:-pair act no(UKCC th--u dar=Lnil I ir,
r=- ce oc zn:� rx:<
C--lp,oy=3 un (C,-,�
,&cr tht cc.".-Ct C�'p:=i:•legal rt=is of an amploye<under tt._woricc,'.co,=,er—aIaon Act
u-nd-_-xtxmd Lbx co?y ofth�, date-: _•c y bo frjl to t!n Chew of for L-
25A CdM,0L 152 1 L P-iti-
-Vcr-&&c va-Ticz-doa and thut f_-Ilurc to!'=--L c=le m
cooci irig of f1m,of up to S 1300.0,0 an1'or of'.!p t")cr.:y n:-.1 Civil 7K=1tja in do T,-,n Cif a Sic;,\Vcr�Or,:=trd 1
S 100.00 i dty xg.timt rrr-
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SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
}} License Number
Addres Expiration Date
Signature Telephone U O
R ' 5e ome lm`aro menY Contractor - u� - � w Not Applicable ❑
Company Name Registration ber
?,-41 J9i2/ i`�L /0(9 Zl g�v/
Add re Expiration Date
Telephone 06-'4�
SECTIOK 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 V,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 acecptable 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
SECTION 5 DESGRIIPTION;OF PROPOSED WORK(check all applicalile)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ j Decks [ ] Siding[{ Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 . Sheet 0
6a.'l.f' ew ous°emnd or�di#ion to ezi tang housing comple ftie'fol"lowing
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
SECT�01�[ a�OWNER AUTHORIZATION TO BE COMPLETED ,WHEN
DWNERSI�GE TNTN ORCONTRACTOR APPLIES FOR BUILDING PERMIT:
as Owner of the subject property
hereby authorize ZV,,,,J / P je-,,419 to ac: on
my h f, in all matters relative T ork authorized by this building permit application.
Signature of caner ' > Dat
as 9sar/Authorized Agent
hereby declare that the statements and information o6 the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print'
Signature of C wpw/Agent ate
a
-De rtment t}se only
City of Northampton Stems ofPerrrut t' �
rm
Building Department C��Drnreway
a _ �a��
212 Main Street Sewer -pt<c�AvailaCnidr.
Room 100 Iitate Melt Ava�(abr
Northampton, MA 01060 TW sets ` stcuc ►+a Ptarts
phone 413-587-1240 Fax 413-587-1272 i?lofifs �iar�s _
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APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE-INFORMATION
Th�ssecfion to be`completed by office
1.1 Property Address:
ilo
Un>t
A/6 �"C. �: / '. /��C� --' Zone Overlay D�str�ct
Efm St D�stnct ,CS D�stnct _ _
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(pent) Current/ ilin Addr7 : fl
r /'o
Y/0 c L �s
Telephone
Signature ( J
2.2 Authorized Ag t: /
5re,w,(k) L
Name(Print) Current Mailing Add ess:
Signature Telephone
SECTION 3- tSTIMATED1 CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official.Use Only
completed by ermit applicant
1. Building `(a) Building Permit Fee
2 Electrical ,_ ..(b)EstimatedTotal Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 +2 +3+4+ 5) =' qua 4� Check'Number "
This Section"For Official Use Only
Building Permit Number: -Z _. 'o ICo) Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
,,'881.R ►N BP-2005-0103
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35-067 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-2005-0103
Project# JS-2005-0125
Est. Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq.ft.): 12806.64 Owner: MIKUCKI MARY A&MARK A SAFRON
Zoning: SR Applicant: MIKUCKI MARY A & MARK A SAFRON
AT. 881 RYAN RD
Applicant Address: Phone: Insurance:
8 81 RYAN RD
FLORENCEMA01062 ISSUED ON.7129104 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 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 Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 7/29/04 0:00:00 19437 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo