36-006 �A34ACh3T4ttt4
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of 'Warthamptan
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DEPARTMENT OF BUILDIl\TG INSPECTIONS
INSPECTOR '2(12 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNM 108.3.4 to
act as his/her construction sups.-zi.sor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,a one or 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 f,,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 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
re fired can DELAY the project until such time as the proper permits and inspections are
ade
AL I understand the above.
ome owner/re
4Writ's'signature'requesti6g exemption)
I will call to schedu e all required building inspections necessary for the building permit
issued to me.
Date d
IV
Address of work
location 1
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F} `rc (rLlf� laf 'NTOrf11a111}Jtoil _
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o DEPARTMEI-T OP DUILDrI-,,G INSPPCrl01.'S
I
212 Main Street ' Municipal Dudding
?Northampton, Mass. 01060
G 'OR1CC;IZ'S CONII')✓NS TION MSURANCE r'1ITIT iviI'
I
T
1'
(II cons=/Pcrmj ttcc)
%VILL a principal place of businessfresideoce at: ----
do hereby cerTifjr, under thc.pa.ins and penalties of pcll y, h:i
O I am an employer providing the followini !,vorkcr's eomoens-nZion covemge for lily
etnplovccs workang on this job:
(LanLr-_nc Conrz--Ml) (Pcuc-. NLI-m�-T) -- (z=:-pinion Date)
O I am a sole proprietor, general contracior o homeowner (c cie one) 2Dd Lave hired
the coasactors listed below wbo have the follo� er's comoen_tzaon pokles,
(N amc Oi Contnaor) (InRranc Comp m)-i�obc-,- NUML-<r) (EtiJrfiduon Datc)
(Name of CoaTzcior) (In.7auanec Comoanvi?ok `usnc^r) (-L.,, ir,Lion Date)
(Name of Cora c1d-) (Lastuanc C0MPaM)-1P0Lq- Numb-J) (Expimaeo Daic)
(Nzme of Contractor) (Lnsuranc-c Company/PoUcy Numbs) (Elpitztioa Date).
rScc!,if acceaa ry-to 6dv<5=rarorzrsaa oe pew' to.11
O I am a sole proprietor and bave no one working for me.
�Q I am,a home owner performing all the work myself.
NOTE:pl=-se be awzrs t>,,.wUc he zr�.v •to cznplay P,- o to da=-a c--=oc or rraa-otX ca of
ant mots th:a tt-ae> .r is u3ielz the bomoowocr r=da oe ea the p ounCs appurtea sr tber_.o e,oa C=�r_lty oeecd-,od to be
employes uoc'.e the..ai:,eti e��•K-..-,:�Aa{GL!152.0 l(S)�:.pplin�on by s bomma-ocr fer a lic5_or penait cr_y e�•id�ee the
legal r=�• of a c=Pioyx aad'dw Workce,Compomatio Act_
1 a+adettaad ibd a Dopy of Lbi.mtemcoa my bw fo.-a.on t4 the Degertmma or Inca ,j Ar od-&OZ-or L.—O-for tb.
�verabc"ciCosieo and t1r_t Ldw-c to An=us}eovcrase uodcr soetioa 25A of MGL 111 csa Id to the i=9caid a oraimi-d pc--lies
eom.i.Lmg ora tint or up to S1}00.00 and!«6mpr6oaaxw orup to Due yr r Lod aril peaaP.io io 6c rorm of Step Work Order Lad a
first or S 100.00 L d_y Lptia-A me
... For dcputaa=-sl u,e Drily - _
Pcrmrl Number _
g=tw- jLUi- 4caniucr- e� -- -j
SECTION 8-CONSTRUCTION SERVICES ,t
8.1 Licensed Construction Supervisor: Not Applicable OL
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
97eatsferee t�i "gin-cil�ceiriec < oatc Not Applicable ❑
Company Name Registration Num er __.�"
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATIOWINSURANCE:AFFIDAVIT(M:G:L.c.'t52,,,§,250(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 under this permit.
Ye undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
--h
amp Ordinances,State and Local Zoning Laws d State Massachusetts eneral Laws Annotated.
Homeowner Signature
i
SECTION 5-DESGRIPTION OF PROPOSED.W.ORK(check att aualicable)
New House ❑ Addition ❑:. Replacement Windows Alteration(s) F Roofing
Or Doors C]
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [p Siding[p] Other[p]
f Descri ' n of Prop d •,O
ork: /v
Alteration of existing bedroom Yes No Adding new bedroom Yes No 1 ,
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
S n ads i� ��e�—r* cr cot li a fEi i cl
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
SEGTION 7a-OWNER:AUTHORIZAT[ON TO.BECOMPLETED WHEN
OWNERS AGENT OR CONTRACTOl2.APPLIES FUR B[JICDI'NGPERMIT
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 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.
Pnn Nf agL�?��2g—�
Sig ture of Owner/Agent Date
Section 4. ZONING All Informatioh 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: R:1 L R:' '
Rear
Building Height '—""
E {
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
I !
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 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 DON'T KNOW 0 YES 0
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 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 NO Q
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 O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
aF .�
City of_NorWampton P°
1, ugding Department
.. . Fn
Z12 Main Street a
Room 100
^ �
rthampton; MA 01060
t,1,,A� ptic le -587-1240 Fax 413-587-1272
v.
_ y
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
CTION'1.-SITE'INFORMATION
This section to be completed by office
1.1 Property Address: � � � ,�
Maps Lot „M. .4 UnFt
Zone Overlay F3isfrrct � ;
1 "
�ElrttTSt.Distnct �' CB.aLstncf
SECTION:2-PROPERTY OWNERSHIP/AUTHORIZED AGENT-
2.1 Owner of Record: -
r'^'""
N e(Prin CT ent M ling Address:
Telepfi6nj
Sign re
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
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fes:
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:
i
Building;Commissioner/Inspector of Buildings Date
28 FOREST GLEN DR BP-2005-1163
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36-006 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2005-1163
Project# JS-2005-1567
Est. Cost: $550.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 15638.04 Owner: BRUSHWAY THOMAS J®INA M
Zoning.URA Applicant: BRUSHWAY THOMAS J & REGINA M
AT. 28 FOREST GLEN DR
Applicant Address: Phone: Insurance:
28 FOREST GLEN DR
FLORENCEMA01062 ISSUED ON:5123105 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLE GARAGE ROOF OVER 1 LAYER
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 Sienature:
FeeType• Date Paid: Amount:
Building 5/23/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo