36-016 (3) �THAM p�,
O O
of 'Nort1jailiptalt
� � 6 �lassaclii�setis
DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street & Municipal Building
INSPECTOR
Northampton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as i.i /her construction sup, The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends 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
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 backlill),
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 G � � understand the above.
(home owner /resid it's sign, ing exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date A
Address of work
location
v'c r• OI'
i�U111)I1�G 1?;s C;1.1oN5 .J
212 Main Street WW I& Buddi&
Noroia,q)w, Maw O]OG.)
� tolucE�I;1s comm titsA��zoN ir�Iszlz�ANC��. l�rtrzN����rr
�:-ith a princi��al place n1"u��!�:•:ncs��fc_;:cicuc, a?=
do hewhy carty,
1 Mil all CII1E)!o1'
cnlplo}'cf;s ;��ot�>>n�_, tail , �:is jt�fl
1 ani a Sole 1 ou tu-t;' Punnal '_:;nn w: OF homeonme; Ade oll; ) :iw Lw Wed,
the contractors Kno Now wnn i _ a the TOiI �:� l;Orke. CJi" ,�.•LS,. '.�...
-
(I�.a.)�
(Name of Conn Ctc,,) �111YIF:Iilcc,
CName of Conn
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not",Kcc tin 0 I cc U:II!I i�,ui cl;h•. . ..• •.�z,'r rr,_rs c~txt t`.�. �..._.._s ,;•.u',c;nr'L2r do:.:z cr._<(;c=*'r.�l �__. ..._
ct,loyc3 upset dl,s czin'-(:.cl c..n!: TI,_c.((11.152. s l(51),r{,.. :)c: y n f.o;a pu r1 for
1tgi1 ctntus of an..Wloyx un;'_cr d.o 1>,'cvl«'�Co;v;wr..tiors Act
I u Amst!.nd Ana cay of th_i c:_!c_<:a t:uy tw(xtirnr-i«j to ttn ll-_t mrsit oCln�u'n cl Ac irrnt�Cfl�on o:!:rain_>cc f Uha
covcrlgc vcrificzlioo a_•u:t1Lt failure to rear-covcizg-�und-r sc .ion 25A al MCI,152 can lend to the im;"Dsificm
oon�isting of a UK of up to S I j V10o nn%w ir.;:ri .�Ik.1 of up to cn-},ar ntij civil;xrultia in �1tx�n of
f ry of S 1 P3.00 a cisy i;.in.t tn-
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SECTION 8 -CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :--------
License Number
Address ,r Expiration Date
Signature Telephone
. . , tor Not
rne , A PP Iicable ❑
Rerstereii Ho irti�rovement,Cbntrac
Company Name — Registration Number
L ess Expiration Date
Telephone
SECTION 10-WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with th!s application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
.caner emption
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 (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 Lop] Zoning Laws and State of Massachusetts General Laws Annotated,
Homeowner Signature _ _ ----.---
SECTION 5"'DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacemen indows Alteration(s) ❑ Roofing .
Or Door
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding Othe
Brief Description of Proposed Work: Pv Q
Alteration of existing bedroom Yes No Adding new bedroom Yes _ No
Attached Narrative❑ Renovating unfinished basement Yes )<�—No
Plans Attached Roll ❑ - Sheet❑
6a: lf'New°"house andkor additidti'to existing housing complete'the.followini ;
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 Woodstcves 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 .
1. 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, or
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/.Authorized Agent
hereby declar he at the statements and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under
}rh'e pains and penalties of perjury.
Print Na -T�—�-
. y
Sign a ure of Owner Agenf�— Date
Y v
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 r
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 here any proposed changes to or additions of signs intended for the property ?YES No
IF'YES, describe size, type and location:
City of Northampton Sattassf P r .I"
Building Department CGutlirve. a. e..;
212 Main Street SewweerfSep rc la A
� �� Room 100 We r IW " vas' r
APR 9L-gorthampton, MA 01060 w0-1
Se s St"r c a f'a s
hone 413-587-1240 Fax 413-587.1272 PlottlSlte'Plan
Other Specify s,
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'.
� d
s,
Map Lot Unit
r/ Zone OverlawDistrtct''
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(P Current Mailing Address.
Telephone
g nature ----- --.
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 b ermit a licant
1. Building
(a) Building Permit Fee
2 Elec`,.rical (b) timated 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: Date Issued:
Signature: -- — — —
Building Commissioner/Inspector of Buildings Date
BP-2003-0869
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Categpry: BUILDING PERMIT
Permit 4 BP-2003-0869
Project# IS-2003-1405
Est.Cost: $5000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 14157.00 Owner: MARTINEZ WILLIAM A&BETTY S
Zoning: URA Applicant: MARTINEZ WILLIAM A & BETTY S
AT: 35 FOREST GLEN DR
Applicant Address: Phone: Insurance:
4 TIFFANY LN (413) 584-2975 O
FLORENCEMA01062 ISSUED ON:4114103 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL SIDING, ROOF, REPALCEMENT WINDOW
& REBUILD CHIMNEY
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 4/14/03 0:00:00 4507 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo