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DEPARTMENT OF BUILDING 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 has/her construction sups: :;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 famity--
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 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
made
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 `// ' Q S�
Address of work
location
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� �a0yE (riff rrf �arfl}alll}�fo�t
43 a c h nrctl a'
W o DEPARTMENT OP DUILDr],,,C I1,4SPeCT1Ot.°S
212 Main Strcct ' Municipal Building
Northampton, Mass. 01060
WORICERIS COMPENSATION ONSLTRANCE A17FMA.VIT
(li txnsx/perm�lice)
NIVIth a prui lcipa! place of businessfresidence at: —
do hereby certify, under thc.pa_ins and pen2lties of pegury, h11
( ) I am an employer providing the followine comocnsa:jo, cove agc for Intl,
emplovecs wor-Ung on t-liis job:
Conr*M') (Pt tic:?vu�irr) --- (r:pir<vor Dzl^)
O I am a sale propretor, general contr2cor or homeowner (ccie one) and have hired
the coax aciprs listed below wbo h2ve, the following worke>'s cocipep_saaon policies:
(i+EID: Oi Co„-maor) Olisurzncz CoinpanyiPoUCi N'uBih—) Dalc)
(Name of CooTzclor) Gas-wanec. Comoaa,,vPoUc-,, Nuacrr) (ixp bon Dac)
(Name of Connaetor) (Lnstu-aac; Compan)'/FoUq- Number) (E.Nairaon Date)
(Name of Contractor) (Lasuran(-- Comcai y/Policy Numbs) (E.xpifation Dar).
(atzac3ti hc--,ilacc�--v to a�'uciiaforasaaoa pcta.iaag to al.l Dots-r�:s)
O I am 'a sole pr-optietor and bave no one worliog for me.
} I awl-a home owaer performing all the work myself.
NOTE:pie be twist ti—v-L-j bcmc vcra .bo c3=ploy pc-ccm to d3 rt,.'air work on c d.•cl--Z of
not mat rhea tc..r-oc—is«-bc."the bomoo we rrsda cc oo the P-oun43 appurtcu tbc--D�T ooc C=a--1p occrd-ud to Lc
cixployc s unCc tho wui c^ c=�,, c.An(GL!152.a t(5)� =ppU=6oc try a bomo3ava far a bc=G or Pa ah z:y c•-idm d-:
IcSA ns_u of a.n e.=,loyw under d-Works e,compem.-t.ioa Ael_
1 u�c land tisa a copy of thi.mtcmc�may bo foc�rdod to the popartmrd of 1-6—icl AaaAc Y OT—of laa+ 4. for th<
covcrasc vczj(c3lioc yd thel[mum to saauc'eovrrm,& undo soetioa 25 A of h(GL 152 rua led to the i=posltioa of aimiaa!Pcc ilWes
0003i zxi of a fiat crup to 51 00.00 Irldf,r of up to Doc yr_r t.ad 6vi1 pmatUa is the roan of a Stop Wort:Ordc and a
fit=of S 100.00,day c&-jag tnc
For dcp�u. Only
Pcrmit Ntunbcr
jv(zn:: Lot. f'
A—Si�natltn of Lia�saJPcrmiticc �>e --
4
SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
S Reasfered'tfiorne°'Irfprb'v`errient.Contractor � � � 4 .§ Not Applicable ❑
Company Name Registration Num er - -
Address 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 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 Icense,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-vear 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 -.-: J
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check-all-applicable
New House F—] Addition ❑:, Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D9
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[O] Other[p]
Brief Description of Proposed
Work: Rep,4 we
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa reacfditiQn.ta eicistir cr ousinxt coimplete the fatlQ�n irig
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION Ta _OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
13-62 1 as Owner of the subject
property I /�
hereby authorize k,,/l2arl-Y
to act op my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, 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. '
Print Name
Signature of 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 Fro
nt
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
(volume-&Location)
A. Has a Special Permit/Vorunca/Rndi ever been issued for/on the site?
x�� ��` x,� �
N8 �� D�7K�� �� YES ��
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
��
NO ��/ uvw / nmu"x 0 .="
IF YES: enter Book Page and/or Donument#'
�� ��
B. Does the site contain u brook, body of water orweLian� �� VV �_/� NO v_� DON70UO YES �~�
IF YES, has o permit been or need tubeobtained from the Conservation Commission?
'
Needs tobeobtoined ��` Obtainod �~\ Date
^�� v�� '
C. Du any signs exist on the pnuport �� ��y? YES v_� NO ^��
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 grading,excavation,mfilling)over 1acre or is it part ofocommon plan
that will disturb over 1 acre? YES ^_,K ) NO �~~�)
�
iF YES,then o Northampton Storm Water Management Permit from the DPW is required.
De nteClt UsWo
City of North,ampton tti l?enn � a
Building Department
I `212 Main Street
i
Room 100 tertWeflysria6
Northampton; MA 01060 F oSesStrucfralars° � � �x
413-587-1240 Fax 413-587-1272 f�lat�Stt Plans �� �� r
P �_.��
APPLICATION-TO CON$TRUC ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
J
SECTION 1 -SITE INFORMATION
_ This section to be completed byoflice
1.1 Property A;dddreess:
:Unit
Overla 'Distr
re ret:
Elm St:District CB District-
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current M ng Address !f,110 .41 �
. � G�L1 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
1. Building /JO e (a)Building Permit Fee
2. Electrical Q (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building,Permit Fee
4. Mechanical(HVAC)
5. Fire Protection IL a
6. Total=0 +2+3+4+5) Check Number 61 P
This Section For Official Use Only
Date
Building;Permit Number. Issued;
Signature:
i
Building Commissioner/Inspector of Buildings- Date
223 BROOKSIDE CIR BP-2005-0779
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 36- 111 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0779
Project# ]S-2005-1086
Est.Cost: $1800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 1825 1.64 Owner: LEBEAU SUSAN
Zoning:U Applicant: LEBEAU SUSAN
AT. 223 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
223 BROOKSIDE CIR (413)584-6045 0
FLORENCEMA01062 ISSUED ON.2114105 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 Sienature:
FeeType: Date Paid: Amount:
Building 2/14/05 0:00:00 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
223 BROOKSIDE CIR BP-2005-0779
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 111 CITY OF NORTHAMPTON
Lot:-001
Permit: Bui[ding
Category: BUILDING PERMIT
Permit# BP-2005-0779
Project# JS-2005-1086
Est.Cost: $1800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 18251.64 Owner., LEBEAU SUSAN
Zoning:URA Applicant: LEBEAU SUSAN
223 ^OZIDE rTD
Applicant Address: Phone: Insurance:
223 BROOKSIDE CIR (413) 584-6045 O
FLORENCEMA01062 ISSUED ON.2/14/05 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: e K
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 2/14/05 0:00:00 $25.00_
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo