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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 78OCNlR 108.3.4 to
act as iris/her construction sup,,.,: ,-isor. Tlie state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or tivo family
divelling, 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
0
OF RUJIDINC;
212 Main Street ' Municipal
Northampton, Mass. 01060
WOP'J ER'S COMPENSATION INSURANCE AFFIDANTI'
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(I"lom"c- of Date)
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misting of A fits of U,, to S of up to e:-.i civil IrJtjcs in d1 Cx l of VYcr1 0h 1 tnj
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SECTION 8-,,CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Re isteretl Home�mpl'OYelllertContGBCtor Not A
, Applicable licable ❑
�G J 1 sCJ C-1W -
Company Name Registration Number
7-,/40/0 zt
Address / Expiration Date
S lMOg CJ/O S Telephone 7/-�-
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT(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 fer which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers` Compensation) and Chapter 153 i,i,iability 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 Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:.7c fA-L t ceh►��G�( G/�Gw�tct<
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
6a°�If New.�fouse ardor addition"to existing=fi'ousing complete tlie.followin ;
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
SECTION 7a OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize _ to ac; 01
my behalf, in all matters relative to work authorized by th- i-)uildinp perinit application.
Signature of Owner Date
TJ as Ow eriAutl,orrzed Agen
hereby declare that the statements and information on the foregoing application are true and accurate, tt OTrriy
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signatu e Owne Agent Date'
ti
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: L: R:
Rear
Building Height
Bldg. Square Footage %
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:
r City of Northampton S tus of Per a e
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��-- — Bulld�ing Department CurbCut/Deer ,, e
212 Main Street Sewe rr%Sepfie�A.a
J!1N _S ��� i Room 100 Wade lWellwaa ab
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Northampton, MA 01060 TwoSetso� tr c rats
phone 41�-587-1240 Fax 411 587-1272 Plot/Sete Pans
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office
1.1 Property Address:
Map Lot'- Unit
Zone Overlay District
Elm St. District CB District _
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
UL+)4_J i'A ►t•�Y _`r�S 'f r__-ZAra1 0-4
Name(Print) C.:rrent V iilinu Address-
Signature
2.2 Authorized Agent::
I Nam r int) --�',rrent Mailing Address:
nat.:re rh r --
SECTION 3 - ESTIMATED CONSTRUCTION COSTS _
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
E uil�iing ! a� `wilding Permit Fee
timnte Total Cost of
--- --_- - or;struction from (6) --- -------
3. Plumbing Building Permit Fee
5. Fire Protection — —
6. Total - (l + 24 I 'll 5)j q�, _ ,heck Number
This Section For Official Use Only --__
Building Permit Number:_ !6 )0 �?—f43 Date Issued: —
Signature: --- --- --
Building Commissioner/Inspector of Buildings
' !!tea►
BP-2003-1113
G1S#: COMMONWEALTH OF MASSACHUSETTS
4 103 CITY OF NORTHAMPTON
Lot: -001
Permit: * Buiftlinu
Category: windows replaced BUILDING PERMIT
Permit# BP-2003-1113
Project# JS-2003-1761
Est.Cost: $4592.00
Fee: PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grout: John Corbett
Lot Size(sq. ft.): 31450.32 Owner: GRANEY JOAN F
Zoning:URA Applicant: John Corbett
AT. 454 RYAN RD
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON.616103 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 16 DOUBLE HUNG WINDOWS AND ONE
PICTURE WINDOW
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 6/6/03 0:00:00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo