35-151 (4) �'1RSSR[}lltStttB
tSi DEPARTMENT OF BUILDD�,'G INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building '
Northampton, 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 sup,,:-,, sor. The state defines "Homeowner" as, ",Person(s)
who owns a parcel on which he/she resides or intends to be, a one ar two farnily--
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
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
¢�ttA}r nT I..
4 -' £ r�:3aicrhnsrlla' —
4 DEPiRTMEIrT OP BUIL_DD\10 INSPECTION'S
212 Main Strcct Municipal Dudding
Northampton, Mass. 010GO
WOJUO:,JZ'S COiVTENSATION UlSURDCE AFF-MAVIT
a pt ipaI place of business residence at: --
(phone:')
(SO-c—c t/cirJ/s=/Zp)
do hereby certify, under tic pp_int 2nd penalties of pc9ury, h:t
( ) I = an employer providin- dle f0llowiM-1 v.-ori:cr S comoensadan cove se or my
emplovccs wor�ang on this job:
(i1`su 12=Coar.MI) (Folic: N'L'-a Y-T)
O I am a sole proprietor, general. contrctor or homeowner(c cie one) and Lave hired
the coouactgrs listed below who have the iollO%I4U' P workers compen_,ation policies:
(Nam-, Of Co„^Cwr) (Insur-ancc coinpan)•/hOhCf ?�t11II1=<:) �_x71idL0 ��1iC)
-- (Name cf Coat vaor) (Insuznc:. ComDaati•�Polie; �urr�csr) (�.»u ion Date)
(Na me of Conn-acro:) (I.nsuranc:Compan)-[Pol;q- NaMbr) (Excirrioe Datc)
(Tame of Contractor) (Losu>aac—c Comrzay/Policy Numkrcr) (Expiration Date)-
(atts.G`7 rAi�oc�1 2scG,irncr�zary to mc?u�iarorMiaoa Pe'u'�to all mar-row) -
a.m a sole proprietor and have no one worldDg for me.
( } I am.a home owner performing all the work myself.
NOTE:plesc be._.rt Ufi r. t�j.bc.,=O, n vbo employ p�--com to So l c roc r�orz on�d <lL�of
mot Moto th_n t'.7oc=rj in whndt the hOtnoowoc ra�da or oc tl�C(�Wn�z�pullLa �IhcCn LT roc C=c-- Y cord-rcd to L-
cnploycz I, the��i dx�u--,ica Att(GUI 51 S l(5)�:tWG n 3ca by a 6om-o--a fc c lick«pcmit n_y c ids«tf c
1ep1 r^ of an cPloy<r under da works,,Coo.P.=,-Coo.Ad
[und.-stxad thrc a Dopy of lhia mtcmcru miy b<fo�.vdod to tbo pcpucmcot of In�+x+iJ AceEc��Off oa oC ln�"`°°°for tho
cova�c v=iScziioo and the LLI=to saauc)oovcmy tick yxZioa 23A cf h(GL 151 on led to the imp03�i.of eimiasl P—hics
carsi:.szg of a rMc or up to S I-Moo and/or impruoa orup to Doc yor end civu Pori-1',ia is t5c form ora Stop work Ordc and a
rim of S 100.00 s day apinA Mc.
__ For dcp.rtm'^z1 u. only
permit Number
Lot
t
'
Wrc of LisccfPcniucc
�
� tr
SECTION 8-CONSTRUCTION SERVICES r
8.1 Licensed Construction Su ervisor: Not A p/plicable ❑
/
Name of License Holder: Z ZZ,2 —
License Number
Address � (•�� j� /_�r� Expiration Date
Signature 'le �'''y hcine
7
Not 9wRe" isfe�ed"Homes fm"°raveri Tent Contractor �µ� R- - Applicable ❑
Company Name Registration Num eE —-
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M:r.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...... ❑
vema Olt
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 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
r
SECTION 5-DESCRIPTION OF PROPOSED WORK(check-all-applicable
New House F-� Addition [],: Replacement Windows Alteration(s) �] Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [EI] Decks Siding[0] Other[EI]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding n bedroom Yes o .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa_ff New.house ai d o`r 'dditi r o extsithc iaO.us ng,corxrg ete the fa[fowei a:
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-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property
hereby authorize
to act on my behalf,in al ers relative to work authorized by this building permit application.
Signature of Own Date
1 as Owner/Authorized
Agent here y eclare that the statements dnd 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.
Prin Name
Sign f 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 J
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
'
A. Has Special di ever been hsuodfor/on the xbe?
' ^-~
x�� VV �~�� xr� '
�� «�� DON7KNO YES v�� -
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry ofDeeds?
NO �� D
�_� um / mvuw 0 ,cu
IF YES: enter Bonk Page, and/or Document#'
�� ��
D. Does the site contain a brook, body of water urwmd ��wetlands? NO v~� DONTKNOVV �_� YES �_/
IF YES, has a permit been or need to be obtained from the Conservation Commission?
`
Needs tobmobtained �~� ��ta�oed �~� Date
v�� v�� ' �
C. Dn any signs exist on the property? YES 0 NO 0
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(clearing,gradingexcavation,nr filling)over 1 acre oriod part ufo common plan
that will disturb over 1 acre? YES K l NO ^_/K l
~_� �
'
|F YES,then a Northampton Storm Water Management Permit from the DPW iorequired.
r
Q Ra
tnpton rtment 212 M' i " eet Sewer-e,
tO04Roq fltister�tle . . ��
Northampt n; M 01060 Foci Sets ofStauctitra!PEans
{?l�glae 4 -5 0 Fe x 413-587-1272
INJf TI
;N I<AA 0 10 60 Cher lxeetfy �
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Th1.1 Property Address: omplefd by office
Nlap Lot Ur�lt
Zone Overlay District
Efm St Di�triat CB District
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED'AGENT"
2.1 Owner of Record:
Name(Print) Current Mailing Address:
'2 ? r Telephone
Sig a ure
2.2 Authorized Agent:
Name Pint) Current Mailing Address:
Sig lure Telephone
S CTION 3-'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
om leted by ermit applicant
1. Building /���,j (a)Building Permit Fee
2. Electrical (� (b)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 Official Use Only
Building Permit Number. Dater
Issued:
Signature:
i
Building Commissionerlinspector of Buildings Date
764 RYAN RD BP-2005-0608
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block:35- 151 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0608
Project# JS-2005-0804
Est.Cost: $1000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: James Roberts 117154
Lot Size(sg. ft.): 29577.24 Owner: SCARBOROUGH HENRY F&LUCILLE
Zoning: SR Applicant: James Roberts
AT. 764 RYAN RD
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON:11117104 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE CARPORT 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 11/17/04 0:00:00 2429 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo