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� DEPARTMENT OF BUILDIJ\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 78OCMR 108.3.4 to
act as his/hwr construction supc: . sor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a one 3r two fami�
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 hour) a roueh 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
m e
I, understand the above.
(Home ow r/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 o? 4 C-
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4 p DEPARTMENT- OP DUILDrNG INSPECTIOI.'S
212 Main Strcet Muoicipal Building
I Northampton, Mass. 01060
i
_ «roR-la RIS C01APE rSATZON cvSVRAN r CE AMA. rl-1-
%k th a principal place of businessfresidence at: -- -- .
_ (phone')
(stz t/ci ty/state/z:i P)
do hereby certify, under the.pzint and penalties of pcgw-y, hai
( ) I arm an employer providing the folJowine'vvorkcr's comacnsadon cove.--Sc for lny
e-wplovecs worUng on ulis job:
(Lnsur-an=Conram, (PCLicr Nu��r) -- (r:-pirrtiorr Dpi--)
O I am a sole proprietor, general contractor or homeowner(Cicie one) and have hired
the coauactors listed below vvho have the folio%ving worker's camoen_saaon policies:
('Namc of Contncwr) Gnsuranc„ Coinpanyill c Ic-i !A1-MLC:) �''Jlid 3QP.l�IIC)
- (Name of CoUUac-100 on-7waac: Comoanti/Pa!ic; NUM6 ) (EaDir non Date)
(Name of Conrraao;) (tnsuranc;Comp-=)-/PoUcy Nasb:r) (Expirsoon Dale)
(Name of Contracior) (Los11Paa(--Comp-ay/Policy Number) (Expirz6oa Date) .
(aIIS.cl]:d4i�-ors!t�cC,ifncco.r:y to a�dvc�cutformL=ioo pczta'. to.11 oo=-ro:s)
{ ) I
am 'a sole proprietor and have no one woridrlg for me.
} I am..a home owner performing all the work thyself.
NOTE:ple be awzn tfi,•wt-jo bomco.�vcr�u•ba cr Ic'y Penchi Lo di =--zc:joo c mpau work on r d.—LU--Z of
ant more tbr-t�tr t�iLc io u'>ieb tix boa�oowocr rvido a oa the go ro:r z7purle*. them t c oo(�-,,�.—11 oc,. d-od In be
eirployct unc e the waj�z�p� .*
All :pptiadoo bye 6om�Qaa rcr_Gc�_«pamn zy c.�d�x t>c
le-gtl-of ea-=Play-<under cli Warico(r Compom.lion Aa.uod- ad rha a copy of Lb;.=a-=-=may be fo.-- -dod to the 0,9_u am orin�rYricl AcndeE'OfGoe or taau+ooe roc d-
-M vtzjreaioa and 11Lt L-iliac to sows`coverase tmdcr soaioa 23A of MOL 152 na led to tbo i-zp i-of Qimi"pca-%Wc
eocusing of a fmc of up to S 1}00.00 and/or iaxpriyoomca{or up to ooc yc and a%il pmaltia fn 6c roan of a Stop Work Ordcr Lod a
rrm of S 100.00 L day Lptiast MC
For J u.c only --------
C / o ./ Pcrm./l Numb-r
1,.L,n" Lot
Sirnacurc of ta�ISCClPccmiucc Date --
SECTION.8-CONSTRUCTION i SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
I
Address Expiration Date
Signature Telephone
S FW stered tfio"r e� en oittracEac `'= Not Applicable ❑
Company Name Registration Num er
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCEAFFIDAVt7(M:G:L.c.152,..§25G(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 Annotated,you may be liable for person(s)
you hire to perform work for you udder this permit.
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
No ampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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y
SECTION 5-DESCRIPTION OF PROPOSED WORK(check allaapplicable)
New House ❑ Addition ❑ Replacement W dows Alteration(s) ❑ Roofing
Or Doors IIIIQQ
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[[3]
Br' Descriptio of Proposed
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
-:.'a.� "'^ _ _L'�"a*'-" a�^ �w.�.;. "sms"" °: .'"""'"��`5"s:`� �C*r; '"'Y`�•z� "=r -'•�€[" -':tom
sa_LNev+rtrOrse�anciirc'd�t�ui cr eelstlaciosrI�cort�tetefEtorl�i> u: v
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
L 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'AUTHORIZATfON -TO';BE COMPLETE[: WHEN
OWNERS AGENTTOR"CONTRACTOR APPLIES FOR'BUIC 040P"'ERNfIT
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 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. '
9 Print N
Signature of Owner/Agent Date
Secti n 4. ZONING All Informat+6h 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 _
Side L: L:' ' R:
-- ,
Rear
Building Height d-
Bldg.Square Footage % -- ?
Open Space Footage _ % r--
(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?
N0 0 DONT KNOW Q YES 0
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T KNOW 0 YES 0
IF YES: enter Book Page'; and/or Document#;
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained ® Date Issued:
C. Do 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 Il
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 ,- NO Q
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r - -- --� _____Qty of N"ortf ampton ai t P
Id Department
�J w
gin Streeteier Vie '
100
I
JUN 1 7 2rthirlp n MA 01060
phone 413-58 - 4P Fax 413-587-1272 fit Ott a�
SWIM
+3therSpeetfi�
"APP_ubAT16N'7d ONSTutuCT,A_qTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Thrs sectron to be com�teted fay office
1 Property Address: T
�/Cif
/c:�-//h;we' I4 Zone Overlay;Disfrrcf.
t
=Elrtt St D�strrct CB D�stncf
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
r
J/// Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
Building (a)Building Permit Fee
01,add,
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee.
4. Mechanical(HVAC)
5. Fire Protection I 4V op 94 0
6. Total=0 +2+3+4+5) Check Number /
This Section-For Official Use Only
':Date,,
Building Permit Number. Issued:
Signature:
i
Building Commissioner/inspector of Buildings Date
20 ALAMO CT BP-2005-1271
GIS#:' COMMONWEALTH OF MASSACHUSETTS
Map:Block:29- 127 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2005-1271
Project# JS-2005-1699
Est. Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 12283.92 Owner: GREENWOOD DIANE
Zoning.URA Applicant: GREENWOOD DIANE
AT. 20 ALAMO CT
Applicant Address: Phone: Insurance:
20 ALAMO CT (413) 586-5486 0
FLORENCEMA01062 ISSUED ON:6120105 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 6/20/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo