29-073 (2) O¢'S1i/U�1P�O
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR "212 Main Street • Municipal Building
Northunpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to
act as his/her construction sups;:. ssor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or tWO amt y
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."
Tfie boil mg 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 fegulations. 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
L understand the above.
(Ao.-ne o.rner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued-to me
Daze
Address of work
location
r
DEPARTMENT OP DUILDf)\,G INSPPCTFOI.'s -
212 Alain Strcct Municipal Building
I Northampton, ATass- 01060
«`OrUcER'S CONDENSATION ON SURA.N CE AFFD),,' ,VTj'
', (Ii ccnsxlpera�lti�)
Vuith a principal place of businessfresid ell ce at: - - -
�tW AIL/j � � (��L�114.clF �(lrl4/ (phone-')
(su-�tic7 rj/SZ3I C.�Zj p)
jdo hereby certify, under the.paim azd penalties of per3ury., ha i
( ) I am an employer providing the foilo%ving iworkcr's comoc isaoon coverage for im
emplovecs wor>ong an tjus job:
i
(Lnsur�c Coo r ) (Policy Numbcr) -- (E;-pim on Day.)
I
( ) I am a sole proprietor, general contractor or homeowner (clicie one) azd have hired
Lhe consactgrs listed below wbo hive the Soho"ving worker's cai pen—talon poiicies
C b n+(^1'1/2
GV\1'tycItc�,t1 � �00 ZJ2111-f
(1,; c OT Cont='Or) (lns-urancc Co mp,an)•�hGbci Nlumh-: ) [1_ti7)1rwjQ (]aLC)
I — —
(N MC of Cona-aclor) (ins.uzner Comoan}vpotic, NLlncrr) (Lair Lion Date)
(Name of Co=C-167) (Lanu-ance Companl•/Poticy Number) (Espi z6oc Daic)
1 -
(1``amc of Contractor) (Lasuran= Company/Policy Numb:r) (Etipiriion Datc).
--
(atucb��oc�!�c�,ifncoc..a_^y w mc?u�iaftxzruu�oo pcutsai.ag to.11 me-�n^a)
1I O I am a sole pr-opnetor and have no one wor' ng for me.
( } I aQt,z home owner performing all the work
myse
iNOTE:pl.-.c be curare t..r_wt-Jc hemcrn4vc-�.vyo cc=plvy pe-z<ma co do �+ cs.;e,00 c rapaa wari on of
cnt mccc 1!_c tt.�ax tsi's in arch the bomoowac maid=oc oa the ITourwsa zppuftcar.tbmm o oa C==-_lty cc,—_:d-•cd to Lc
eixplaye s uric=the..ui c ---,'�Am(G Lt 52-=1(5)),=Pptintioa try a bom-o a—fir a!ic-or pc-ma=y eacdmrx the
IePl n-^„of as C=Ployx under tlzo work4ea Co�ao?atioo.Act
I undert.aad ib.d a copy of thii mt.eoyan tarry bo foca•urdad taa tba Dry—,W of ln�nuicl naadeass'Office oC ir>rut+ooe for th.
covc•�,Sc�ciLciioa nad tYu C:iltac to sazrrc�covcraso tradC..•.-+;on 23 A of}.tOL 111 m l�to the i�xpraaioa of cimins!pcasltia
oomi.iztg of a);ne of t�to S 1 500.00 andlor oCup W ooe y-,:r cad c�i1 p�tia io be form of a Slop W or?;Orde snd a
fi=of 5100.00 a Q_y t piast CX_ '
For dc,s.rtaaT�1 u.c onty
Pcrmlt NUML—`
m":__ Lot
Si�aiurc of Liossc-JPcastittc.: ��e �
.. t
SECTION 8-CONSTRUCTION SERVICES 71
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
3:'Re ster¢d`Nomem'r`avemerrtContraa,� Not Applicable ❑
Company Name Registra ion Num er —
Address 1 Expiration Date
i l C ✓� / /1/� Telephone �_��! a)
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAWIT(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 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 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 A-anotated,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
i
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SECTION 5-DESCRIPTION-<OF PROPOSED WORK(check all appllcablet
New House ❑ Addition ❑, Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [0 Siding (0] Other[0]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa fNew o�se: srd o a d t i + xist� c> dusi ft�coftidt"h f tit" II10:
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE-COMPLETED WHEN
OWNERS AGENT OR`CONTRACTOR'APPLIES FOR'BUILDINGGPERMIT
I, �h n!/A A6 t'V/Z—: as Owner of the subject
property
hereby authorize )J tA//%►rL r n �, i_c)rz►�jl=
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, 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.
Print Name
Signature of Owner/Agent Date
' , ^
.�
Section 4. ZONING All Informati6h 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
Rear
Building Height
Bldg. Square Footage % r—-----
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
'
A. Has a Special Perm it/Vahanoe/Findi ever been issued for/on the site?
'
NO 0 DON7KNOW 0 YES 0 �
IF YES, date issued:"
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONTKNOVV 0 YES
IF YES: enter Book Pug and/or Document#
�� ��
B. Does the site contain obrook, body of water orwetlands? NO v���� DON'T KNOW x�� YES �,�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
'
Needs tobmobta[omd v=� �bteiomd �~\ 0mta |ssued'
x�� �~� . �
C. Do any signs exist un the proparty �� ��� 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 0 NO 0
IF YES, describe size, type and location:
E Will the construction activity disturb grading, or filling)over 1 acre ovisd part ofo common plan
that will disturb over 1acre? YESK ) NO K^_,]
~~� �
|F YES,then o Northampton Storm Water Management Permit from the DPW is required.
-
City of NortF ampton e
Building Department ' w
212 Main Streete
Room 100 e catty
Northampton; �MA 01060
phone 41`3-587=1240 Fax 413-587-1272
and �
F
`b
APPLIg0,0,N TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This sectll' to be completed by office
1.1 Progerty Address:
Lot k Unit
2 c On.
Zone Orrerlay�;Disrcf
EIS St D�stnct CDistE�ct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
7�h F�70'Vf e to k /]as I "tv b ltw L2&
Name(P'31� Current Mailing Address:
r� J
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS UG.°L
Item ~ Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
11 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
Date
Building;Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings- Date
i6
38 ACREBROOK DR BP-2006-0306
GIS#: COMMONWEALTH OF MASSACHUSETTS
MO.Block:29-073 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0306
Project# JS-2006-0448
Est.Cost: $6000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin Edward T Corbett 119488
Lot Size(sg.ft.): 13460.04 Owner: HOWE THEODORE J&EDNA
Zoning:URA Applicant: Edward T Corbett
AT. 38 ACREBROOK DR
Applicant Address: Phone: Insurance:
1 TERRACE VIEW (413) 584-2546
EASTHAMPTONMA01027 ISSUED ON.912012005 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: Date Paid: Amount:
Building 9/20/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo