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DEPARTMENT OF BUILDD\'G 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 super , 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 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 Clot 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 r',egulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before baekfill),
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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4 DEPARTMEIJT OF DUIL.DrNG INSPECTIONS ,
212 Main Strcct Municipal Building
Northampton, Mass. 01060
I
WORICCR'S CO'iY(P ENSA770N GNSURANCE AI IDAVI-l'
(li ccttsxJperm�ttcc)
\IIIItll a principal place of businessfresidence at: — -
G le
(SIIr-t/c�t-•/szalcla
do hereby cerdi under dic.pa_Lns and penalties of penury, h:i
( ) I am --in employer providing the follo%ving!vrorkcf's comocnsado, cove.—.,;c for ul)
employees lvor.�Ong on tins job:
I
emnu-m=Cocnaz ) (Polio: Nu_=t cr) (r:•pir<tior, D=-)
O I am a sole proprietor, general contractor or homeowner(cicie or!e) and have hired
the contractors listed below wbo have the folio%vino worker's comoep_m-bon policies:
ONaric Of Co:,racwr) (IRR f3nc COtAD111}"/l�GUCi ?�lltQ1�C:) fr+_�La�oR D]tC)
(Na me of COntT:mot) On_7wznce. Companyi?okv `umcci) (-Ex-D moon Dale)
1
I
(Name of Coarraclo:) (Insurance Company/Podcy Nambj) (E�pirdoa Date)
(Name of Contractor) (Insurance Comoaay/PoUcy Numbrs) (Expirddoo Datc) .
(ansu�l �oczJ r'xG,ij"nccaa._-v to aic?u�dz 3af0rma:ioc pctaiain6 to aU ooc-_Lo:s)
- "`a sole proprietor and have no one worl,3ng for me-
( ) I am..a home owner performing all the work myself.
NOTE:pt.—.-be awwr tt-fi,•. t.jj.bcmcen�vm u-bp cmvlcy Pcryc=to do c•i-• • c-=c,00 a rrnu—cric o-i.d..en= of
any Moto th c ttsm=rs in«txich the bomoo, o rcxido or ca tSc aouac;,z7pu�tbeeo�z ox�e-_Uy oeer6=vd io he
`Vloy`U�`j the ^mac cc=P --+"on Aa(GUI52=1(S)� wLi=600 by a bomeoa=for c bra_or pctait c=y e idm«the
ICS21 etaye of i Ploya uOdrr dio WorkoeL Compooyal Ad '
I
I uadcrMxzd tha a copy .
oCthia mt®om ouy b.fo�.d to tbo p�r��o¢of lndusri.J Accdcab'OSLoo oC Irrw-�ooe far th.
oovcrisc veZ[caioc and th:t U-==to saauL bovcrd�uid,soaioa 25A of),IGL 132 c.Id to the Lmposi ion of eimia pen-title
coozi-r,$of i tint orup to S 1500.00 irtd/or iMpriu>am=or up to ooc yrur nod a�i]pcaihio is t5c form of.Stop Wort Ord,and i
fish o(S 100.00 1 day 1pin11 Mc
For dc.rtm=_�I u.c only -
f'ctMt NttIDt7CS L40t
1.dap•
Si tuyr f Licrsi_sccfPcrmiucc e .
SECTION 8- CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
..sR' �&j. �4 b.YaG�.Re wx
21
Not
9Re Tsllere torne#ma�errterr,Coriti"acar n Not Applicable ❑
Company Name Registration Num� e�r - --v-
�l4 vNVc- .1.-i
Address Expi ation Date
Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M:G.L C.14'4 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 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 rime,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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all ayolicablet
New House ❑ Addition ❑. Replacement Windows Alteration(s) Roofing
Or Doors E3
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[0] Other[d]
Brief Description of Proposed*
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
.-:. ;;; r..e x> a:z,�•."='�'0'�',«?�'- 2,�,.,v,�ta;rs�-^?s..ac.,�..ro =.aE .�.'d"�,...�"-"' r� *='*�*+�_ ""�`' :' 'i.�"w'�i�'»
6a.IFfe�nc- roxrsertac� cctif>LOctoexlstncfioosln ._oorrISiefefh ,_ t6 >4ifg:
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 APIFILIES",fdn'6U1 LDIRG PERMIIT-
1-
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
as Owner uthgrizedy
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my nowledge
an elief.
Signed under the pains and penalties of perjury.
Print Name
—7 4'"
Si of Own r/Age Date
t
Section 4. ZONING All Informatibit 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:'= t
7
Rear
Building Height --- '
Bldg. Square Footage %
Open Space Footage _� %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill: ? i
(volume,&Location) i
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW Q YES 0
IF YES, date issued:'; c
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW t YES 0
IF YES: enter Book Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location: j
D. Are there any proposed changes to or additions of signs intended for the property? YES NO
I i
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 Q r NO 0
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
I of Nortf ampton
jLuiJding Department ,
12 Main Street
Room 100 -
�? 2��5 ampton; MA 01060
I"" phone 41 -58�-1240 Fax 413-587-1272
WIN
` 11A�AlICATiON`TO CCI CT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
i
SECTION f-SITE INFORMATION
This sectton t�be com [eteofce .'
1.1 Property Address:
':UrtFt ;
Zone Overlay District
EGnSt D�strtc CE3 DisMFf
SECTION 2,-PROPERTY OWNERSHIP/AUTHORIZED'AGE NT"
2.1 Owner of Record: p '�9 5, y' C L! C=7-
i � v I� /J�+ t'�o rh✓ �c j s�, L u c 1
Name(Print) Current Mailin Address:
"? 7 3T79 7?tea
Telephone
Signature
2.2 Authorized Agent:
�J� � �-/ Vii,--.S��� -�l Q�ln'►o c,��_ c / ����,�.
Name(Print) Current Mailing Address:
ture 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
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
1104 BURTS PIT RD BP-2006-0193
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 160 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildinq
Category: BUILDING PERMIT
Permit# BP-2006-0193
Project# JS-2006-0286
Est.Cost: $9240.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq. ft.): 11543.40 Owner: DEARBORN SANDRA M
Zoniniz: SR Applicant: John Corbett
AT. 1104 BURTS PIT RD
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:812212005 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS & SIDING
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 8/22/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo