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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 his/her construction super ..,,or. 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
t
��[37 ACh I76 Clt5 _
DLPARTMEA'T Of' LUIIDD�G INSPECTIONS
212 Alain Street ' ASumcipal Building
Northampton, Mass. 01060
WOPUCER'S COMPENSATION INSURANCE A MAVI.T
v"Ith a principal place. of businessJres deuce
C10 11C1'CU}' CC'i1I}, L'n:'cl L}1C -D ii1S and pCil 1t1C: of pC(JIlf1' Mar
VI am an employee- providing the 10110',vinQ • OI'r C1`S GOII7pCnS3110n GO`'C•r2 C -0' In}'
employces working on dies job:
(1=, 3 e.: Compam') C':C;Ni1:n17Cr) (F->:pir don ate)
l ) I am a sole proprietor, general c-:)I1*LT2c`0r hor eowop-r (C"Lrcle one) anc' t:a`,'e nirc�
the contractors listed beiov .,to 11a c, the :011 `porkers cor pence on elic es:
► 1 1C 739 _ 1[ a
e of Contractor) (Lns. nc Como Pc?ie Nttsn>xr) x,irn--4n Date.)
(Name of Contrcto-) (71�su _nce Come,wPe!iet' Ntrly r) (1_..., i. Date)
(Nlamc of Co-inclor) (1n;I-slc COi ?�i/POi1Cr 1vI7.rI]li2r) '.X,'i::il Dale)
- (Name of Contractor) -- (Insur1r1G ComT�—=Y Pohcy (Eg.i-::inn Date)
(..".7tl Lt ad'{1t7 CY:11 f_:'Gt:!::!•'�:•.v.^::� r:::'�^::::'K:':v::CK•r="'•'::;:�-. 'li:`:C::�_:'i:'•1
l l ilSTl it sole })(OpI]CLC)i i?i11 ililvt', 110 7110 ',.'�;?liiif, tOi Iile,-
} 10111 2_ honiC 0�'ri1Cr uC':CY1171n 1l i_. ii.`;'S lf�
N0'11:plcac tK hw2lc till!-.v�nk hf!{:Da1r_:3 :once. ar:--n r m cis:-;:air .._
not uxcc than t roo t:zti+,s ir,ui dt he k::��r.:z,_re.:< z oc oc'` g t:.-3 ate•rtcr r1 ihcr o 2 r{earrall.i o:r.:::.:::5
car.ploycr3 u_tijcr tiv-Lwri"n m—Z:•.—:_tix Act(GI,1,231(5))•'-�:,':_-'ic::i,y a hrnn o.N-�cr`:cr a l cc c cc p:r
legal status of cn amployec uodcr thn Wori:c,,�s ckom,+c Zion:`.ci
I tuidcr tend diL a copy of t}ua r_.y to(o,<nrciod to[In IYtxifL�wL of Indzu riJ A,ci&cw.'0' of 1' `ru?_c for tlx
covmtse vciTlGtioc and that failure to!,au-eon-r_g^„un3ct scttic-n 25A of?.!GL.152 can Ic_d to the irnpJsib-o;c:-i:_1 pm&ll:=
cvmiutmg of a fur_of up to S 1 500.00 n:tJ Y of::p to cr..}- ..-.j civil perultics in dt�iix n c(a S!r.:`,V r-ri.Ord__rd
firms oC S I WN a day
._ For-6,pwul',-j u> oily i
t
5inature cif i.icon_cJi'^rm;ac: r
S€CTONB CONSTRUCTION SERVICES _
8.1 Licensed Construction Supervisor: Not Applicable ❑cpsooC8
Name of License Holder :_ Gk, ` Q
License Number
Address d{00 Expiration ate
411 3 SSG C/IF � �
Signature Telephone Ph 5163 t�-I'
Reg s e e mparouemen on#rac o ��, � Not Applicable ❑
C� 10 9 �C)o
CompanyName Registration Number
3 A �.�,fs _..__ — (! ILIA G GQ : _ ql4 ho< .
Address Expiratiufi Dat
Telephone---!q/3 A- (S 9 130
WORKERS' COMPENSAJON INSIIRANCEAFFIDA"VIT(M'Gt"L.""c.
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 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 frorn 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
t
SEClO
M fl RUMP.90P.OSE DWO:RK checkaffa' licale
-
New House ❑ Addition ❑ Replacement Windows Alteration(s)-V/ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signss Decks [ ] Siding[ ] Other
' [ ]
Brief Description of Proposed Work: [ ` �c �ci rye oc �.
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
oit�i.otn to.ex:rsting� ` ">�sang co pie e, �Tefollawln :
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?C
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 0 construction
i. Is construction within.100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes Nc
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
SECO 1=tUT021ZATlON �46ib E COMPL.'E?ED WFIEN
0 1M1Iaf�S ONTRACTOR APPLIES FOR BU G PERMIT
ZA 6 ?JIC� C'w% as Owner of the subject property
hereby authorize ��l I i IL_ _ to acs or
my behalf, in all matters relative to work authorized by this building permit application.
Sifnature of Owner Date p
as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penal {es of perjury.
Print Name r
Cb
Signature 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: DO L: R:
Rear
Building Height
Bldg. Square Footage �j %
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 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 VI) DON'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
Building Department
212 Main Street
Room 100
m_pton,,
�,�24 `'� a4 I 7.1272
1
IIJAPPTjOJ 1� �N T, L,TE, EP I NOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
DEPT OF BOL,"",INSPECTION :NSF 7Ci iCNS
t >,a "�, A Qi060
SE - SITE INFORMATION
1.1 Property Address:
av
+a aLS
;EIin.St bib L. � ^ 8 D,�str c >��.' "
SECTION-2'- PROPERTY+OWNERSHIP/AUTHORIZED;AGENT
2,1 wnnQx ofT Record:
Name(Print) Current Mailing Address:
�/ Telephone
ignature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone _
SECTION>3: