29-042 ¢TtUMPT �
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�� tie Crz I of Nart4aniptan L r
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15T DEPARTMENT OF BUILDDNTG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '
Northampton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction sups:.•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
Fzo :GoyE 6T of
A E 51 artchncclla' -
DEPARTMENT OP DUILDD\10 INSPeCTI101,S
212 Main Strcct Tvfunicipal Building
Northampton, ATacs. 010GO
%Y O R SC E R'S C O N'Q'EN S AT);O N Get S URAN -C Al, T
O�CCIISx/j)cTn7J tiCC)
v-,I h a principal place of businesshesidence at:
I- (l;h .S p` -7-�
(sac ty/stailap)
do hereby certify, under ctie pains and penalties of penury; hat
i
( ) I am an employer providing the following %vorkcr's comocnsabo, cove age for Intl,
employces wor-LJng on this job:
i
ir-auon Dal`
j (I.>ZCU.r-�=Conr,�•) (Pclic: ?:L:z�r) (r�-p )
O I am a sole proprietor, genera] contractor or homeowner (ci cie one) and have hired
the conua(:tors listed below wbo have the follo%ving worker's comtnsailion pobcies:
ONamc of Co_ntnci0") (In umnc: Comps i)'/PGUci (—EXOlr--au0n D.11c)
-- (Name of Contractor) (Lasuranec. Comoan)vPotic-; Numcrr) (Expiration Date)
(Name of Coaraaeto,) (In_surancc Compan}-/Pot-q- Numbu) (Expiation Date)
(Name of Contractor) (Insurance Comcauy/Policy Numb:r) (E��irtion Dau).
(aaxob addii'ocal cbcct irnccca y to ctcudc iarorm,:ioc pctajnjnz w.11 oo�oco�)
(� sole proprietor and bave no one world.ng for me.
{ ) I am"a home owner performing all the work myself.
NOTE:plcsc be ao A=tti,.u1Jc bca=o mcra—bo mil%pcaoaz to da c repair-or-c oo a d..cll_z of
not mote the L=tr terra in uiicb the bomoowDr=r=d=oc oe the p-ounca zapurten r1 tbeco c c we G=am .ity oecrd-rcd to be
citployca tt the wve rr'z ca=-"iiaa Act(GL152-=1(5)),appltaDoo by n bomcom-o.=fca c b -�a pmnn ray c rdcax tl c
IcVJ n-.,u of aA=Ploy"under flan WorkzeL Compo=af Act
I un4crxt d tha:oopy ortbu carte may be foewo t nd to tho De ccd of ind.r,crid Acn& OQoo of In-+��ror th
a a
ooveige vciratioc mnd Ut.t L:du=to Lccurr'covcTiCc taadet aoeiioa 25A er MOL 152 as 1cd to the impositioa of cirnioal penalties
eoosir,aag of a Ciao orup to S 1}00.00.rtNor iaprboo orup W ooc yc=r rod civil pcoxkia m t-form of.Stop Wort;Order and a
run o(S100.00 r day L pinst ax
Fmjt Numb=
� . I— p�-- Lot r ;
e
Sign,-tturr of LiccnsccJPcrmiucc .
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9-,Regis#ere MomelfmprovemensGontcac4or , ,• g Not Applicable .D
16 Y"Jo
Company Name Registration Number
c-!e s1 7�i�/o to T
Address Expiration Date
Telephone SQL `��'�—
SECTION 90-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL.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...... ❑
LVem
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition ❑ Replacement Windows Alterations) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[o) Other[CA
Brief Description of Proposed
Work: --4 K1 St(J �_Lr t1i J-7 t-- Liv-i ! S LJ ✓6 Lv, i
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
`;•.mfi33-t�T',�. 5z ,.,.. ,, . ` - 2§`. .. g
6a.=fNew tloclse.and.:br.. ictit�or> tos-ex�st�r?a.hous�nrl,;<compTet�te,4fo�Iowmg:
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. Masscheck 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 7a-OWNER AUTHORIZATION,-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTORAPPLIES,FOR'-BUILDING PERMIT
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
j�� vU �,� c�« as Owner uthonzed
en hereby declare that the statements and information on the foregoing application are true and accurate,to the best of m dge
elief.
Signed under the pains and penalties of perjury.
Print Name
Si of Owner Lent) Date
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Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete 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:r
Rear
Building Height
Bldg.Square Footage %
Open Space Footage % -
(Lot area minus bldg&paved i !
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW l YES
IF YES: enter Book Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r'' • 1
1 y Of Northampton . k
F
Bu g Department
Y r
Main Street y
Ro m 100
�j`a Northam tOn, MA 01060
phan,�,4135t7-1* Fax 413-587-1272 a �
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address:
Thus sectF6n to be completed b�rufffce
Map 1t.ot Untt
t+-CA v c v v N r— S x% L t_S Zone OyerJay Drstcict
EImSt Dtstoct' � `" CBAis#►ct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
t_�✓' KOVCa L'�S
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Aaent:/^
Name(Print) Current Mailing Address:
�-
ignature Telephone
SECTION'3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building O)'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) // /, p Check Number
This Section For Official Use Only
Building Permit Number. Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
r
BP-2006-1332
GIS#: COMMONWEALTH W LTH OF MASSACHUSETTS
'4 7 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildinq
Cate orv: BUILDING PERMIT
Permit# BP-2006-1332
Project# JS-2006-1965
Est.Cost: $1111.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq. ft.): 11979.00 Owner: CAREY DENNIS P&JOANNE L
Zoning URA Applicant: John Corbett
AT. 49 PIONEER KNOLLS
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON.61612006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 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: Date Paid: Amount:
Building 6/6/2006 0:00:00 $25.002440
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo