36-128 Grzty of Xort4au pton I
� 8 ,�lassachitsetts
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • MuuiciPal Building
North,unpton, MA 01060 �M
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sups:visor. 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)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
ttt/MP", +�-\
0
C�iziIj zt# '>7z` litt�It}�fc1tt
� � 6 �lasaxcE)usctfa �")
DEPARTMENT OI' BUILDIT( INSYECI'IONS
212 Train Street ' AlunApA BuiN ing
Northampton, blass. 01060
WORTER'S CONIPENSATION INSURANCE AFFIDAVIT
�li:xns:cif�`nl:ttec}
NvAh a principal place, of businesdroOdence st.
do Why cm in", undur the i'k)l s aiiC pC i]21h S of pC'.f�111}� thflt_
( ) I -.Iii an enlpioycr proviNg the :ollokng wrr_cA wEpc umm covemy for 1ny
eillployees worl.-ing on Ilis job:
--------- —
J= rancti CoiDpamy) (i olli .,Numbcr) r;-tfon Date)
O I ani a sole propAutoi, general contractor or homeowner (circle one) and have ltired
the contractors listed below who }lave the. follu'ving workers compensation poiicics:
(I'lilmc of Contmctor) — — insumncc Conlr,:nv;i'olic,Numb:,-)
(Name of Contractor) Onsunincc Comj i:v/Pepe; Number) mate)
-----
(Name of Contractor) �In ttrux Comi;anpiPol�c}� Nuuti��r) 1,:r..:. _.Date)
(Name of Contractor) (ItuZ rangy Com /Polrcy Numb�r) (Eqhmuon Date)
(r.ttadr u�{iticXral Shct ifr.c-cc-v t-:'.c io-�:xic c:::xnu(i�pitain:nr t�ell c.<:.:a�<.«)
)) I aill a solC prOpil CUr 2!l`J have no one for Iile.
dill holliC all I!1 P.'C�rc; iiiV�Clf.
co(axxe than tlireo unite ir;t�I �r Ir.F.:rn uixr real u oa the L:Y zi��u cc_nt Lhado a:c:n<Ec wally r_r.drm :o t
employa3 under tIx work rl'a Act(G1,152,zi l(S)), for a LC 1!.c cc Irr;a:r av :n rr c Lac
logal ctwrc of an oaplo}'ec under tL�Wev?La'a C�xn;x<rifion Art
I undcrYiand Ih,t i coyy of t}i�ct atci:aat:u.y be forwnnied to tIn Dcixirtmait of Iadzufrial Ani'�t�0ti3 coo of fi✓uv>.�for Un
covcsngc vcrifi�iion and that fa l ttc to ccuuc covcraga ur 3zr sc t ca 25A of htoh 152 can lead to taxi mpo-s lion of rurea l pc allies
romiating of a fat of up to S 1,500.00 a:t14x irris c;l of up to on }tar aM civil PCrraltia in dx form of n Stcp Wcrk Order tad a
firm of S 100.00 a day tFr,in:,1¢r_.
Foc-cSq;utnritsl uic u:ly
t�naturc of L ic�:r,cJPcrnt� r� .�� �
SECTION 8-:CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
ray Not Applicable ❑
ReTT'r-" 1 e� tp t vement�Cgntr.`acto',,, � �� -� pp
Company Name Registration Number
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...... ❑
,' O W :.nee d n -
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 buildinll 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 Zonino Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature `� /'� <�ts� ® _
SECTION DES(:RIR,Ti�IONOF PROPOSED WORK(check all,apnlicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 141
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding] ther [ ]
Brief Description of Proposed Work: cc/ Y �� Q tom'e
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative o Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
6a If�Newho e�ar�idor d`tlition`:=to�existing:Fiousin�:=complefiethe:followinir:
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. 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 .
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a OWNER'AUTHORIZATION -TO BE COMPLETED WHEN
OWNEkS.;AGENT`OR°,CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby authorize to ac; 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.
Print Name
Signature 0 wne Agent Date
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
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 there any proposed changes to or additions of signs intended for the property ?YES
No
IF-YES, describe size, type and location:
City of Northampton
Building Department C
212 Main Street 5 r S
Room 100
Northampton, MA 01060w Sets ;
phone 413.587-1240 Fax 413-587-1272 Pio 1Slte t .
. ,
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,beAcompleted by office
�-1 /� /.�✓'�cI��'C S/ E? l�r�/ Map
!
Zone Overlay:Distrtctf
Elm St. District_ CB District
SECTION«r2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
f
2
Name(Print) ® Current MailhnU Address:
—Xe
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTIONS - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Elec:?rical (b) stimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
14. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5) Check Number D
This Section For Official Use Only
Building Permit Numbers Date Issued
Signature:
Building Commissioner/Inspector of Buildings Date
279 13110061D CIR BP-2004-0461
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block 36- 128 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category: BUILDING PERMIT
Permit# BP-2004-0461
Project# JS-2004-0662
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 31188.96 Owner: COMO RICHARD W&PATRICIAN
Zoning.URA Applicant• COMO RICHARD W & PATRICIA N
AT. 279 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
279 BROOKSIDE CIR 0 585-8908 O
FLORENCEMA01062 ISSUED ON:10121103 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL CEDAR SIDING & SHINGLE 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 si nature:
Feel e: Receipt No: Date Paid: Check No: Amount:
Building 10/21/03 0:00:00 4002 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo