36-041 of Martha np#art Z
�A55A[h1281tt5 -
DEPARTMENT OF BUILDrNG INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building �1,44
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 super :isor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be,a one or two famiy—
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
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O4I1tN I PLO
F� yE (yif� pf Porfl1zalliplolt
W o DEPAR7MENT OP BUILD0\1C INSPPG•TIOIs -
212 Main Strcet Municipal Building
1\,Torlhampton, 1\Tass. OIOGO
WORKER'S COI TENSA-nON L'`tSU�CE AFFMAVI-l'
I Q '
�' (li ccusxlpermi ttcc)
v.9th a principal place of businessfresidence at: -- — --
/_fib,0
teji A-DS(UrQ ' • (phone') �S Y ✓
(50-c—Vc7 tylstatrl a p)
do hereby certify, under thc.pzins and penalties of per3ury, :hat
( ) I am an emplo)rer providing the follo%vin�,!worker's coinocnsado, covem;e for Iny
etnplovccs Nvorlong on tills job:
(Il�'S1Lr??lC✓Conr,:ml) (POUC-, ?:u_-aocr) (r':-pirdor, DzL.)
I
O I am a sole proprietor, general contractor or homeowner (ci c:e one) and have hired
the conuactors listed below rqbo hzve the following worker's coc.2oen_-,26on pc5cies:
(i+nIDC of COnr^CiOr) (1RSUI311C;^. Coln Van}'iFlGUC-i Nll1a1R<T) -- �-i:J1iJ;30R D1lC)
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(Name of Contramor) (Ms'urznec Como nvi?oUc \tuncrr) (\Dim6on Date)
(Name of Conaaao;) (Inswanc; CompareyfPOUcy Numb j) (Expratios Daic)
(2�ame of Contractor) (Lasuran Como
aay/PoUcy Numbb`r) (Expu-,600 Datt).
(naac3 addi-�ocal s'�ca.irncc+csa--v to a�cv�rnfocyv.�oa pczlainia6 to.11
O I am 'a sole proprietor and bave no one worming for me.
( } I am.2 home owner performing all the work myself.
I�
NOTE:pl=..tx ewzre t*,•vtJe bemcovven ut,e>xploy pcsoai w dJ ^, -r ao c rcpaa—ori eo.d..en_C of
aot @ort:tb_a L:r =rj to\c'h7 lbC 6=oo v,=r=di oc Oo IbC 0"WaF.J 2pp1ttG0_2'1 IIICY_D LT Do(C^=)=Jly oc=d=-cd to LC
eitployes u �e Lb'--i r C=2p---,�on Ac((611152-a I(5)�apptia000 try a bom=aae fc_lies_a permit c=y a id roc LL-C
legal n=^, of en e-r:ployx uoder it-WoclvdL Coq.—Li.AaL
I uadcztaad tba>oopy of thin mt—sa may be for urd.d to the Dgrcmao¢of In.d—W AnodrssY Offioo oC l=w—for th.
oovaisc te'Gcz"oa=nd dL--t L Itat to EcOlm bovcrxge undcr sccUoa 25A of MOL 152 m ltd to the i=posi ioo of a-imiaA Pcm%W s
ooasitiag of a fwc orup to S 1}00.00 artdroc of up to ooc yvzr and aril pcozhia in 6c form of a Stop Work Ordcr Lod a -
r=of S 100.00 a d_y Lp ast M-
for w ^f't u,c only
. (�CrIDJt Nt1IDt)CS -
,CIS Lot
St iurrofLicrnsalPccrnit[ct ——D&Te— -j
SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction SupeervvisJor/: Not Applicable ❑
Name of License Holder:
License Number
Z�l (�.h, ,F P n C�>� �' Q �, (C�ii'��, i1, y Ci1U - C S L 6 S�'
�-� '~T —' ��� Expiration Date _
Address
Signatu a Telephone M1
� :
9 Reap Ye'" Home mpro emeh Contra or _ g - Not Applicable 11
Company Name Registration Rum er - _-
Address (h Expiration Dale
" p -ACV 7 moo'
ele hone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G:L.c.1.52,§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...... ❑
31 Hom 0WHE" nTxem on
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
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SECTION 5--DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [-1 Addition ❑.; Replacement Windows Alteration(s) ❑ Roofing
Or Doors Cl
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks [p Siding[O] Other[E:]
Brief Desc 4p ion of Propose
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
{fN..�
6a ewmhorrsenr�addir trex><st�nc� ios�ncl�°cami�lete thol�atnr:
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
Q pQ7— as Owner of the subject
property
hereby authorize
to act on m ehalf,i al five to work authorized by this bwlding permit application.
Signature of Owner T Date
as Owner/Authorized
Agent h I i6,ihat the statements and information on the foregoing applicati n are tru and a curate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury. '
l
Print Ndm�e
Signature of Owner/Agent Date
Section 4. ZONING All Informat-j6h 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 i
Setbacks Front �-f
Side L:I R:` L:' R:!
Rear
Building Height
i
Bldg.Square Footage —'( %
l 1
Open Space Footage % ---
(Lot area minus bldg&paved ~ {
parking)
#of Parking Spaces
Fill: I
(volume I&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 0 DONT KNOW 0 YES
IF YES: enter Book Page: and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 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 0 Date Issued:
C. Do any signs exist on the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
a
City of Northampton
L
Building Department
212 Main Street
M14
Room 100
Northampton; MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
j This sectwn to be completed by office
1.1 Property Address:
% St/P273-dP177— PO . Maps Lot Untt
a
it Elm Stu District CBp�stnct .
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT'
2.1 Owner of Record:
- o Bjri �-
Name(Print) Current Mailing Address:
if
Telephone
Signature
2.2 Authorized Agent: e ! AVI Ia _�`�
e �s /a�n C /9Ff
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
1. Building (a)Building Permit Fee
1 _
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
Date
Building Permit Number Issued:
Signature:
i
Building:Commissioner/inspector of Buildings Date
1053 BURTS PIT RD BP-2005-1242
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36-041 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: roofing BUILDING PERMIT
Permit# BP-2005-1242
Project# 35-2005-0485
Est.Cost: $8000.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CUSTOM CRAFT INDUSTRIES INC 115081
Lot Size(sa. ft.): 12501.72 Owner: STARR ROBERT E&STEPHANIE D
Zoning:URA Applicant. CUSTOM CRAFT INDUSTRIES INC
AT: 1053 BURTS PIT RD
Applicant Address: Phone: Insurance:
64 MAIN ST (860) 623-7800 WC
WINDSOR LOCKSCT06096 ISSUED ON:6113105 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP &SHINGLE 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 Sienature:
FeeType: Date Paid: Amount:
Building 6/13/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo