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DEPARTMENT OF BUILDING 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 sup(,:,"sor. T he 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 your), 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, Ll 111.tuk understand the above.
(Ho wner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date U )', I O 3
Address of work
location
� 6 lY�z57HC}itt6CII1 � _-
m llEPfiR1'1 fE NrI 01, BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 y
WORTCER'S CONITENSATION INSURANCE /. FEDANFIT
principal place of busiresslresidenc
('phone
CIO 1101"eby CCI II 1 UII:1cl" tl1C' i)2IfIS ::iTti pGiT-Ics 01 pc:rllll�" I12(_ -
I :iT, an enaplo per pmviding the io11ov.'r;.m4 '•:Oi�:CI'S COfI1pCI1SaU011 GOVCr:' C .Or IIl}
emplovees wor�dng on t?Lis job:
(Ins,=an Company) (?elic;Naal3cr) --- (Eypiradoa Date)
l j I ar1 a cote proprietor, g'.enerai o-' homed"mu (ciicle One) and have hired
Cii` COI]LT2Gt0rS tISted be.0tr ,to the :L:` '•1OfiterS compeIl�-'nn pokllts:
C I=e. of Conti;mr) (�RSL'^.1C COIIl^:::] :PO11�1 t�llfTl�Ci} fix;= -.:ca Date)
(Name of Contr:c<o-) (Lns,Ir, ncc C0me-:1vfPo!ie)' 1""Um r_I; Date)
(Name of Contractor (lnati3Ilc�z (-t� :?il;iltiQl:C: Nl1II]1F1I) '\::i1:'=Q ' Dal,-)
- (Name of Contnctcrj _ (Ins,m ic-z Com--=yfPolicy Numb---r) (E::n :::tion IDaie)
(alt.�Gl=dditi ern!ac._et i..._ -.— ::�io-::!'�_':�...I�Y^u]i e;:i •--..' ei;c:c.r_.._,..•.1
I <LTl c1 ole l?1 OpI1l C ): 2I11 it ? ' 110 OI? Ut viii fOi :]T
�� ?ill Il lioli?C O�VI1C' liCiiC"IT]lIl 11l i1 V._..: iii-vsC. �
?'i0 I'f::�1CvK tC R14-3:C L-:+:'.11::]C t'.C!iL'J�\1Y_r:\��rJ c:-plC�, — r� � - ••. .•
not uicte th n tl rto uniu i. u{ dt he f'. . .;ttr�rc: a a; `u :.:J a r._r crsrl Lhcc c=c cxt Lcrsilly co.::i_:: :o tti
c^ployc3 ucr"cr tIr wc;1:n'_ar •;: i:n r (( L152 !(Sl; -,: ._::ic;;'vy n hot:lro«-ncr`ar a ccu a p:r:: r.- . .... r c
Itga1 ctataas of cn cmplOyo(uz)drr tL'C Wcvkoez iocv-, '' Iion:"ct
I undo,.-::,end ch,:s ccr,,y of ttu ctatc::r�c_uy be tostivnrclod to ctr�[Yjxiltz,ut:of Lnd„s:r;�M-+L�:�CiGao oC i::t,rL?-,a for t!m
OOvCm&t VeClflC,im and ul--t rItare to f—auL 152 can Iced to 6-irnpositioo cf-r.;.:.ir_I
03-=isting or a fur_orup to S I SOO.CXJ 01 1-1;)to c• }- a:-.l civil pcnittica;n tt.c fonn of a S!c-,, _r.d a
firm of:;10,0-00 1 day I:f-in:t tn:.
Foc kr,u1111 t j u.o crtly j
Pcrm;t Numtxl—
tll7lb-�
Si-Inatufco i.ic�n cJPcrnr;ac rt:: }
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SECTION 8=,CONSTRUCTION SERVICES
Al
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
W-Reg's e - 'om m�ro�ern`ent + +driA ,„
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
'0 -AFFIDAVIT AFFIDAVIT(M G:L. a 152, § 25C(SECTION 10WKE ,C, 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 fann
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 ti�,�
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SECTIOND1=S. TONOFPROP..OS6D��IVORKo check'�11-a�a' lica�tile �a
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding K Other [ ]
Brief Description of Proposed Work: �'Cemt v-1
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
OWN: roakr G eXistingh rro sin'g�comp�te a Fie�followrntr
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
SECTIOf� 1111 ER�UFJORIZATION TO BE COMPLETED -WHEN
OWNERS AGEN �R CO YTI ACTOR APPLIE53FOR BUILDING'PERMIT
Tr
as Owner of the subject property
hereby authorize to ac;. on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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 penalties of perjury.
_ N— �26ckc:A-1-, U r' ( ( i IAIr
Print Name
fI1-�
Signa eZf Owner/Agent Date
M �
/
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 `a
Frontage u� }
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage U %
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 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:
e. w
G{tp of Northampton
wilding Department
212 Main Street
Room 100
N 0 Northampton, MA 01060 e
phone 413-58�,-1240 Fax 413-587-1272o� ;
INR
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATI"ON
1.1 Property Address: r `
This'sect�ontobe comp etedby ff�c" <
2 � F . g
f t l �C MaP L t
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SECTION 2- PROPERTY OWNERS.HIR%AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) 1' Current Mailino Address:-.
--FA�1 hi'� 1-�.t-� 1M.� 1 I S ' 2
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
S.ECT10" -ESTIMATED CONSTRUCTION COSTS"
Item Estimated Cost(Dollars)to be Official Use'Qrily
completed by ermit applicant
1. Building D Jl a
(1 Building Permit Fee
2. Eiecrical (b) 'Estimated Total Cost of
Construction.fro.m 6`
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 +4 + 5)T Check Number
This Section For Official Use Only
Building Permit Number: Date ssued:
I' Signature:
Building Commissionerllnspectorof Buildings Date
OK DR BP-2004-0576
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2004-0576
Project# IS-2004-0807
Est. Cost: $3500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 14984.64 Owner: HELLIWELL GREGOR&ELIZABETH
Zoning:URA Applicant: HELLIWELL GREGOR & ELIZABETH
AT: 29 ACREBROOK DR
Applicant Address: Phone: Insurance:
29 ACREBROOK DR O 582-9018 0
FLORENCEMA01062 ISSUED ON.1117103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VINYL 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 Occupant Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 11/7/03 0:00:00 3072 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo