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DEPARTMENT OF BUILDDIZG INSPECTIONS /=
INSPECTOR '212 Main Street • Municipal Building
Northunpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sups.:- sor. T he state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,a dne or two_amid -
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 r'.egulations. 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 insyection. 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
r
i
i
DEPARTMENrT OP DUILDD\,C MSPPCTtot.'S
212 Alain Strcet Building
Northampton, Mass. 01060
WORICCR'S CONIMENSAZTO.N >,iiSURANCE Al
O1 ccns,-Jperznj ttcc) -
wlth a principal place of businessfresidence at: -
MI�f 0"pz-n: (phone!) SOO'b 2r7/L
(sit/citrlsZ=,Zc p)
do hereby certify, under chc.painS 2nd penalties of penury, -:h2i
( }
lam an employer providing die follo ne!workces comocns:::3on coverage for ill}
employees worlong on tilis job:
(Ln ranc Conn,) (Potic:Nv r) -- (E=;-pim or. DaL-)
( ) I am a sole proprietor, general c0007actor or homeowner (c c:e one) and have hired
the cooiTactgrs listed below cvbo h2-ve the `oko k n2 worke>'s coc-oen_saoon policies:
(INamc oT Co_t:2c-,or) (Inn:ranc Coinpwi)'f7obc ?�t1 Q1cC:) fI�':J1rJGQ1 D.11c)
(Name of Conrzcior) (Insu=cc- Comnantiv701ie Nt mcrr) (Ex-Dirz6on Date)
(Name of Contraclo:) (Lsvra-nc: CompanyfPolicy Numbs) (Erairtion Date)
(Na.mc of Contracior) (Insurancc ComczaylPolicy Numb`r) ( .cpirtiion Datc).
(aa�c3 �oc7t=Sca.ifacccz_ti to crcu�infvca+coa per� tc.il oc�.ca a)
l am-a sole proprietor and bave no one working for me-
( ) I am.-a home owner performing all Lbe work myself.
NOTE:Pic=be aairc 0-� Jcthc�mrA�++�vc�a..-bo caploy p,=-.,a=co dD -• c�r�oa c rcpza--ark as,d..,rt:-Z of
aot lIIOft tlLO t 3v tmt'.x is����the c �+ u I=d.OC oc do 1-ouo j 2ppLLrtcc ^JbaC-D LT ax C�--Dy OD=.d.-cd to be
cmplcyr=and the..=�-ti rte=.,,--*ca Ac:(GUI 5)-_.1(5)�rypliaaw by.6ommava fc «pcmit zy cvi i—LL-
'c-P'I cta3u of ca cr:Ploy.r aadar d.o WwkS e.C.oa�a Ac-
1 Dopy of chi.mt®em may t e fog--,i d to tba Deparimce¢of Inm:xriJ A,-d-i OT-nr L.A + for a-
covc�^c'rcirctioa aid ttt_t C:.iltac to sc�uc fovtZ�ta�dc sccion 23 A of hi4L l52 caa l�to the i�os2ioa o(cimiazl p--atlIie
eoaii:'a of a fine ortp to S 1_�OO.OQ.rtdlor j=pri3O=Dc=orup to Doe Yr=r tzd evil pm.-i.is tx form or.Slop Wort:Ord--.ad
fig o(S I DO.00.dsy Lpin-a mc-
For dcp.ra.�-.�1 +,c arty
Permit NumNxr
Sitna�^cOfLtcu lPrr,r,;tt�� ce 1
SECTION 8-CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
S:ReQis>fereci E hie lmR,/ICC vemeft L,oiitr a " ' y Not Applicable,t0
Company Name Registratition Num er - —
Address Expip6tion l5ate
S L^1 G/O S Telephone.—M,?
SECTION 1'0-WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M.G.L.c.152,§'25CF6#
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 1083.5.1.
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 buildine 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,allaooiicable)
New House [_� Addition ❑:.; Replacement YVindews Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[p] Other[p]
Brief Description of Proposed �— �
W ork: 4U S'It--�%- kl A't c P/V)f
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roli -Sheet
sa, ��CJew��tase�ti��°-e�rdtl�tiQ`� ;.�a�exstECi��1�c�iisi�ct�._ca "ttitet �he� (ix��rg:
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-_T`0 BE.COMPCETEB WHEN
OWNERS AGENTOR dONTRAdTOkL APPLES FOR BUILDING=PERMIT
I, 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
as Own CAuthoriz ge_ hereby declare that the statements and information on the foregoing application are true and accurate,to the best n�wiedge
lff .belief.
Signed under the pains and penalties of perjury.
` G
Print Name
Signatu wn gentjr Date
`
'
Section 4. ZONING All Informatibn 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
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
'
A. Has a Special Perm it/Vahance/Findi ng ever been issued for/on the site?
'
NO 0 DON'T KNOW 0 YES 0 �
IF YES, date isoued:
IF YES: Was the permit recorded at the Registry ofDeeds?
NO 0 DO0TKNOW 0 YES
IF YES: enter Book Page, and/or Document#
-
�� ��
B. Does the site contain u brook, body of water orwetlands? NO �~��� DON'T VV «_�KNOW YES �_�
IF YES, has permit been orneed to bu obtained from the Conservation Commission?
Needs tobeobtaioed ��� 0bta�nmd �-� Date
�~� x�� ' .
C. Dn any signs exist on the proporty �� ��� YES �~� NO v��
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,excavation,orfilling)over acre or is it part ofo common plan
that will disturb over 1acre? YEGK`~�] NO � )
/ ~~'
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
'Qity of Nortf ampton
uiiding Department euva, r
212 Main Streeteu�r t
^' \Room 100 rcarta r`
'-. Iorthampton; MA 01060
,phor�p�41�687-1240 Fax 413-587-1272 Pats ans rte
C7fE e Epee , V k �a
Ml�APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Address: Thrs seetron to be comtetecf byoftice
Loth' Unit
Zone Overlay Drstrrct
,.
Elnri~Drstrrc CB DrstFrct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
rr�iryy
Name(Print) Current Mailing Address:
ure Telephone
SECTION 3-ESTIMATED'CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (ti)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) Check Number
This Section For Ofticial Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
�� BP-2006-1194
GIs#: COMMONWEALTH OF MASSACHUSETTS
No=
W CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-1194
Project# JS-2006-1764
Est. Cost: $1390.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq.ft.): 9016.92 Owner: ZUCKER ROBERT G&ANDREA HEAPS
Zonis: SR Applicant: John Corbett
AT. 80 DREWSEN DR
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:51912006 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 5/9/2006 0:00:00 $25.002422
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo