36-140 v
O¢��Mp�Ow
�RSSRC}�IiStttS
t
DEPARTMENT OF BUILDD4G INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building
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 his/her construction sup lsor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fMU_y—
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 e,egulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfilll,
sonotube holes (before pour), a roup-h 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
V_11_1 u understand the above.
(Home owner esident's' ignature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date � o ' '� DL�
Address of work
location
r
o¢TtW tnTO J..
F} °E (rii of �rrrfll�)1t}iton ----
RJ � �li7lR(tinsctle' _ =-
DEPARTMENT OP BUILDD\10 INSPECTiot.'s
212 Main StrCCt ' Municipal Duilding
Northampton, Mass. 01060
_ «`ORrCER'S CONQ'ENSr1`l['IOl� L'ISURACE :�I'I'II);iVj
(]i ccns.^rJperu»ttcc)
,I iLh a principal place of business/residence at: ----
(Phone.
(s-r�t/ci ty/stalcta p)
do hereby certify, under the print and penalties of perJury, :hat
( ) I am an employer providing the follo%ving%vorkcr's co[npcns_n:Jon cove age for in)
etvplovices worUng on tills job:
(Insul-an Corer v) (Pclic; Numb-cr) -- (T=,pira[ior,Dal`)
( ) I aln a sole proprietor, general contracior or homeowner (ci cie or2e) and Lave hired
the consactors listed below vgbo have the following workers co policies:
(,Namc of Co,, ac-,or) Onsumncc. Coinoan}•trohc-i NU_MLC:) Datc)
(Namc of Coacaaor) (I.risurane;, Compagw?oGm, Numcrr) Date)
I ,
(Name of Coaa-aaor) Gasurancz Compan}•frolic}• Nnmb,-j) (Expi z6on Date)
{
j (Name of Contractor) -
(Lasuran� ComcatrylPoLiey Numbs) (Ea�irtion Date).
i (aascb�u�ocat t'xC,traceeza�•to c�cud:inrorm,._-joo pcna.iaix�to aL 000�-ra:�) .
i
j O I
am'a sole proprietor and bave no one woridng for me.
' I am.-a home owner perfon=g all the work myself.
NOTE:pl=.=be aa-yrt tfi_-ktJe b0cDC0 1>CT1.i>o employ pezoo=to da = -c:joc ar rcpar work on t d—UL-is of
inot morn th—tb--tmitr is bomoowocr rc3ida ,oa the gova6 zapu.rtca=rs tbeaa L-r ooe C=r_!ty acrd rcd to be
`Vloyc-z unda the w—i:cr'�cc pc_1im Act(GU452sr 1(5)�:.pptiaboa by a bomcoaaa fw c!ices:.or pamh=y cvrd=c c the
Icga1 eta�a<of an e_rployx wader ttao V1o[Scoli Coosgomalioa Act
- [uvdatrand this a copy or thix m.c®cm may be raranarded to tbo pcgenmm¢orIn.duvicl Accida�'office or l,�ur+ooe ror the
covcra�c vairatioa a.-td th=t C-iltz•e to sa�uc Bove-rye tmdrt sxZioo 25 A of}.(ot 151 as tcd to the ia»sitioa of eimia.�!peaaltia
coazir-�*(&Gx orup to S13oo.00 and/or j=qruoomcy orup b occ yr3r r-Dd civil panYia is 6c roan ora Stop Work Ordcs and a
IjI rim of 5100.00 a dsy Lr&i=ttx
i - .. For dcp.rta+�I u,c Doty ---•----
jI''~~�� rt.rmt[Numi)cs
6 V ." ) 0 N/,zP° Lot
Si�tt Li ccmiticc e
r .
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9,Realstered Home Improy@ment Contractor: Not Applicable ❑
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...... ❑
11. -,Home Owner Exemption
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, St to 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 Windows Alteration(s) ❑ Roofing
Or Doors E]
Accessory Bldg. ❑ Demolition ❑ New Signs [EI] Decks [0 Siding[p] Other[❑]
Brief Description of Proposed
Work: EkmDy2 ®\& � A ,& )C�e1 : Syr, L
�
Alteration of existing bedroom Yes `� No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ✓ No
Plans Attached Roll -Sheet
€a.If New h use and r addition to existin housiln complete the following:
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
I, , as Owner of the subject
property
hereby authorize
to act on 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.
Prin Name
Sig ature of er/Agent Date
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
Side L: R:: .,.. .. L: ... ....., R.,..
Rear
Building Height _
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
arkin
#of Parking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T 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 DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 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 0
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 NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
I pa rt Me ' usp�niy
City of Northampton 'Stittr�sf Pglro% {
Building Department waPetiit
212 Main Street 5erterlep�tiA±e`itatiillww
Room 100 tatr/uue yHeb) 'y � r
Northampton, MA 01060 Tws�Sets of Strtilctutl.glans
phone 413-587-1240 Fax 413-587-1272 Pipys ans
Uther:Spectfy �
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 by office
'I c,) (
G �(ok)K:5 a e Map Lot Unit
�71(>a4\ce 1 1 w1 O �67 Zone Overlay District
Elm St.District C13 District
SECTION 2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
A PwA U- 1 r",rsfior\ { 'R u b e.>(k 'C. L m4 t CCi rct 1 urn
N e(Pr.' t) r Current Mailing Address: .
ut3 - 5�31� 585"
Telephone
S re
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 1000 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
A 04
6. Total=0 +2+3+4+5) Check Number S—
This Section For Official Use Only
Building?Permit Number: Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
256 BROOKSIDE CIR BP-2005-0406
GIs#: COMMONWEALTH OF MASSACHUSETTS
MIR:Block.36 140 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:roofing BUILDING PERMIT
Permit# BP-2005-0406
Project# JS-2005-0540
Est.Cost: $1000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 15071.76 Owner: JOHNSTON AMY&ROBERT EARLE
Zoning: Applicant. JOHNSTON AMY & ROBERT EARLE
AT. 256 BROOKSIDE CIR
Applicant Address: Phone: Insurance:
256 BROOKSIDE CIRC (413) 586-5853-0
FLORENCEMA01062 ISSUED ON:1017104 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 Signature:
FeeTvpe• Receipt No: Date Paid: Check No: Amount:
Building 10/7/04 0:00:00 2989 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo