29-082 (2) �(t1AMpl, ~
O O
of Nort4amptan z
�11ASSAC�(1t8[tt5 -
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northmnpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as I—is/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
PL understand the above.
(Ho a owner/resident's si natur equesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date/1 JD3
Address of work
location
F�ttinN ITT �`
.. P 6 !?lassRthnsrtte '
m DEPARTMEit"I' Of' BUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northaml)toil, Mass. 01060
WORKER'S COMT ENI SATTON INSURANCE A,FFMA V1T
(lic�r..x'r�:rmittcc)
w4h a principal place of buslriessIrc`;idence ar
------- -------------- ---...---------------_.---------------------- --(,phone'=1------ - -------
do EICrEby ce j, wOer le p:ns and pcn tLic;i Oi 7Ct�llf�f, thfl_-
( ) I a a an employer providing the f011ov;iInt '•.01'r:C S C_om!)C11Sau0I1 (';OVC."f:`'C f(Dr, my
employees working on this)ob:
ommomnay Comprm') c' c Nu-mbcr) ('rte pinion Date)
( j I a n1 a sole proprietor, generz± conti-c`or honleov;oer (ci;cle one) and 'tlavc hired
th,,, coIIu actors Used Wow wil0 i1z 'e th;: i0-1} Q, v`oFke;s compen-s t:On
CN=C of Contmctor) Nwnbcr) Datc)
(Name of COnt??C`or) Date)
(Name of Consamm) (Ins rs1 Com uly/?ol;c Numrf_-r) ?.x r tic... late)
- (Name of Contractor) — jasu mce Comr„_v!Poky Numr.=.r) t.L'::ni :tior D<te)
l I <LTl is :;QlC 1?1 OI?I1C Ji <?i11 have no 71:C .',' ;?niiih fol ?Pc.
I P111 a home OW]le' 1)Ci-f-u-mliI' all i'. v""_..: iI clf.
1'r
NO"r::plc--sc be nwa:c tli;:.v�ac E <-c0«Zr s s c.:�I ;;x. c n:: i 'saacc ar:'r �m cr pa it«";;, ^.._wvcl!i-
not uxre th_a ilu-cc un?s in tct:;di he 1.:. -.v rc: or a: nci CCr)'--r111}'
cam'-ploye3 u_x er t}r=vca:Ts cc •�::Girc,t.((-rL'.52�s!(S)!,a1:;i_ :ia: a hota ovvxz`:cr e l;cc' e a pera:i:::
legal status of an cn?ployor unu 4 n Wo[c.c Ccx,?, _- uc'n�,cL
I u_•vd=umd on a copy Kt O. auy bo fof v'wd-j to ttr:lY_ixirtzusL of ItdiLZri-J ActvjUcn 'Oirao of(:::+_+r ry=a for tlx
covcrzge vrsif catioa and that failure to cnV-_c`�urd-: 25A of MOIL,152 can i:d to the impositiorl 011
c—isting of a firr-of up to S 1-M.00-n_"(Y ir.:nrxr,zz:_of::p to cr.:}- ..:.j civil pcmltics in do finn of n S!a;r`w"az Ch=nrd
day 17:61r.1 tn..
.. C w do—w—eal arse wdy `
PcTrnit NunilK:r
..5!°natter C ql I.tCCn.';C:.;IhCrllttilr:l .......r:1.'�:•
SUCTiON 8,Iwi STRUCT10N SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
Regs'fe"t�e" "o�rnelmp ouementC^^+rartn Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTIONIOy YI(ORKERS' COMPENSATION INSURANCEAFFIDAVIT(M G.L..c 152, §25C
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 acccptable 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 o Massachusetts General Laws Annotated.
Homeowner Signature r
I
SECTION d R ITZON OFPROPOSEdYWORK check al{la {icabie
ME „ ; ..
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing .
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: Anmo�k:
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
6521 f e—w"Mou d -r "Cdr't oon to exist�ngWhoUS"eng�ca�mp e e he follow-ins
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
SECTIONC� lixlNER 1UT,,0RIZATI0 N TO-BE COMPLETED WHEN
01NNERS�A E� f�0?CONTRACTOR APPLIES,FOR BUILDING PERI�AtT
I,
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
I, AJ as Owner/.Authorized Agent
hereby d tare that the statements n info ation on th foregoing app ' on are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury. j
(-, reacr✓�4- N LLB w�� /�i �al���l-I�� � � vuc �
Tent Na
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 X M AC VCS
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
� 5 �ee t•
Bldg. Square Footage 1 100 S1 %
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 IJON'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:
a -
Cit of Northampton ;
ing Department "P
2 Main Street
I Room 100
N E Impton, MA 01060 :
phone 41 58 1240 Fax 413-587-1272 P it;
4
4.
4 APB `I t T, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION=
1.1 Property Address: X Thts sectto tob"' compreFetedbyofftee
ap
�—_
Lo `
y
r e M GL D I DLe'-- Zone�� Oyerla tst ct
EIm StDtst�ict � CB Dts rtct
__.W � .,.x . ..... ..
SECTION 2 -'PROPERTY:OWNERS,HIP/AUTHORIZED AGENT
2.1 Owner of Record:
_C--7 6Ctl-X. A2l
Name(Prinq Current Mail Address: �.X/
_ Ll) !) L90-1
Telephone
elephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature
Telephone
SECT10N,3 - nM' AT EO'GONSTRUCTION COSTS
Item Estimated Cost(Dollars) to be Official Use Drily
com leted by ermit applicant
V 1. Building s6o (a) Building Permit Fee
2. Electrical
(b) .:stimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date:fssued:
Signature:
Building Commissioner/Inspector of Buildings Date'
t
29 ACREBROOK DR BP-2004-0374
GIs#: COMMONWEALTH OF MASSACHUSETTS
a`:Block:29 4082 `1 CITY OF NORTHAMPTON
Lot: -001
Permit: Buiid[M
Category: BUILDING PERMIT
Permit# BP-2004-0374
Project# JS-2004-0538
Est.Cost: $1500.00
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 () 582-9018 Q
FLORENCEMA01062 ISSUED ON.1012103 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 10/2/03 0:00:00 3043 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo