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" DEPARTMENT OF BUILDINTG 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 iris/her construction sup,.: ,,ilsor. 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 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)
++ ++1 Wlll call IO schedule Gan l fC utt Cu tu.l•luui•l_l r, i1s-Gltiv'ij ucccSSai y •vtr r+I-
issued
'b n nYa"
rmit
to me.
Date
Address of work
location
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w o DEPARTMENT OP BULL-017),,10 INSPEC7i01.'S
212 Alain Street MUDicipal Building
?Northampton, AT ass. 010GO
ti's`O RICI R'S C O IAT EN S A'XZO N [N S URAIN CF_ A FM A VIT
I
i ccusxlper'm�tics)
v."ith a principal place of business/residence. at:
2 x/ NUPE/ rAk?i 70
do hereby certify, under Lhe pains and penalties of penury'.; -ha l
I am an employer providing die followint worker's coinDcns?:30P covera�c for Ins
etmployccs worUng on this job:
Corer�) CPolic:Nut r) (r':-pirrrion Date)
O I am a sole proprietor, general concraaor or homeow-Oer (circ:e one) aDd have hired
the consactors listed below vqho have the 'oUo%vjDp, worker's caLpenszDion policies:
('Nan1C 0. Co:'tT cior) (In urarlc CoIr101r7)`/P06C-' ?�rltII1�G:) �ti�t;JUOn��:flC)
(Name of COnlTcior 1'
MsuraneV C.omDaa)vPo.re; Ntt.06rr) (i:xvir.:tron Date) ,
(Name 0(CGUMCla�) O suranez- ComT).a.o)•/PoUq• Nwnber) (Expirrien Date)
I
0-" e a. vGud- i0r) (Losuranc—c Compa.ay/Policy Numbcy) {Expirtian
(aQarb_'6_4z��ocal 6cd.ifacco _-y to i 3%v&iafbrmi moo PCrU.M.,G to.11 co=mco:a) -
{ ) I am 'a sole proprietor and have no one worl.-ing for me.
( ) I am.a home owner performing all the work myself.
NOTE:pl=sc be ccr2rt:tb. �tjc hcmcc A+ -nbo employ peons w �s.;e.�ao c rgair—oric oa of
cot mace the a Lh�-its in tech ttx bomoowxK r raido or oa the V ouDo zppurt,-a=tbera e r o C-lly oca d7nj to t e
cirploya —6-the..v 1 o=P==•ioa M(GLI52n 1(3)),zpplintioa Gy n homooa=fcr c bc=_oc pcmit ci<y c.-k—tL-
IcSa naau of as crgioyx uodor dso Wack4et Compa=al ArZ
[uodeszwd tfuc a oopy of thin=Ut of o y be ford erd.ed to the Dcgenmcoa of Indattrid Accdr ay MOO of roc the
covcnsc vairalioa am that L-iltac to Loa=)'%oast tcodcr soczioa 23A of MOL 132 aw Iced to the LMP�oa of cimiaat pmxW=
coasiring or a fiat of trp to S 1300.00Nee irapritio�of up to ooc yar r it pmztia n tSc form of.Slop Woric Ordcs and
frm of 5100.00 a d_y sVLia1a me
F �-rmil Numbar
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Y. a.li P Lot `
S i piatun of Liascclp/Fe J
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder
License Number
65
Address Expiration Date
2�/ /J e) K-(� E% 1r1 �6 eJ f'Nd/�' 0
Signature Telephone
" Not Applicable ❑
Company Name Registration Number
J C0 �� y�`l 1 V �5- �j�c� c U C/ �t� /-' Lew
Address Expiration Date
QQ �
1-DA-1 &XTelephone �g�`7/� 1 �•�-�gi a. t7 sa
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...... ❑
S wk
IUNR
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-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 buildine 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
,_. c.t_x.f..........1.....e�+..(So.. 1 T mvc Annotated vnn may be liable for person(s)
.Employees for injuries not resulting in Dca•ul)V1 u,c ivtanJa�dauov.. --�• - -•• -___
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Wi ows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[ ] Other[O]
Brief Description of Proposed5r � ���T
Work: '2z f/kt /6' t�ti'�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
' ' btf i�� owings lfNew f o m :
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 7a-OWNER -T0 BE°C.OMPLETED wWHEN
OWNERS AGENT OR CONTRAG?TOR-APPLIES.FOR`BUILDJNG PER'-MIT
1, (�f mz�" 0'" rU 5/-- as Owner of the subject
property
hereby authorize 7 L apr14�+ `Z
to act on my behalf,in all matters relative to work authorized by this building permit application.
v 'i
Signat of O Date
A) Z 'J 19 0' as door/Authorized
Agent hereby declare that the statements and inform on 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
Po-
0 C
Signature of Qtr/Agent /� Date
° -
L , .
. .
Section 4. ZONING All Information 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
Rear
Building Heigbt
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bIdg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Vahance/Findi ever been issued for/on the site?
�� ��
NO �~��/ DONT KNOW \_� Y25 x��
IF YES, date issued:
IF YES: Was the permit recorded ot the Registry ofDeeds? '
��
NO �� DODON'T KNOKNOW YES
IF YES: enter Book Page! and/or Document
'
�`t �~�
B. Does the site contain u brook, body ofvvotarorwetlands? NO �~� DON7KNOVV �~� YES �_�
IF YES, has permit been or need to ba obtained from the Conservation Commission?
Needs mobeobtained �-\ Obtained x—\ Dota �soed'
.
C. Do any signs exist un the property �� ��� YES \_� N� �~�
. '
IF YES, describe size, type and location:
D. Are there any proposed changes toor additions of signs intended for the propertyY YES NO 0
IF YES, describe size, type and location: `
E Will the construction activity disturb grading or filling)over 1 acre mis it part oiocommon plan
thaw0dioturbovor1ace? YES [ ) NO ����
��
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
^
Depar,dent use only
y of Northampton statusot ?errrlr` ��
u ing Department tt Gt9tl13ri+ientayP
_\ .2 2 Main Street se er�sep�tc a�tatultty
t Room 100 -w- erne� ab�Gt�
z F
� Northampton, MA 01060
hone 413-�87-1240 Fax 413-587-1272
P
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
This,section to be completed bKcSffice
4
973 u2rs �Tj t unit
,�/O 0, G t: ✓,� Zane OvertayD-stmct
l— a
rE1in St.alstu�'. � `,' =C6 L�IStCICt
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�vn y AW 4'r-0
N� (Print) CurzenMai Add s l S ! t X'
:ea� Telephone
Signature
2.2 Authorized Agent: `��)
�h�� L /� ej I ap,► /U'6 P/'t�i '�'n A4) i'f's
Name Print) Current Mailing Addr ss::,
S a-7/x'7
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION,COSTS
-
Item Estimated Cost(Dollars)to be Official Use Only
co pleted by ermit applicant
1. Building Q✓ (a),Building Permit Fee
1J.:2-ao
2. Electrical (b)Estimated Total Cost of
'—� Construction from 6
3. Plumbing <Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection oe
6. Total=(1 +2+3+4+5) � c5 6 Check Number 6
This Section For Official Use Only
-Date -
Building Permit`Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2006-1078
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-1078
Project# JS-2006-1592
Est.Cost: $3200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq. ft.): 27834.84 Owner: POWERS GARY R&PATRICIA E
Zoning: URA Applicant: B & R Siding
AT. 973 BURTS PIT RD
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON:411012006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL SIDING & 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 4/10/2006 0:00:00 $25.0020309
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo