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S" r� 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 78OCMR 108.3.4 to
act as iris/her construction sup,, : � 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 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
1 c,,( ,,� understand the above.
(Home owner /resident's Vignature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location U 70 v tr -5
F-10 1MA of O�o '1
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DEPARTMENT OF BUILDING INSPECTIONS
212 Main Street ' Municipal BulUng
Northampton, Mass. 01060
WORTUT,R'S COMPENSATION INSURANCE AFFIDAVIT
1 InittCC) -
with a principal place of busilles--Jresidence t.
do hereby certify, under the pains and penalties of perjury, t}1flt_ -
O I am an employer providing the following .volkcl's compensation coverage for Iny
employees wor,-ing on this job:
(Insurance Company) (Petit:Number) (F-x ation Date)
—1 I am a sole proprietor, general contractor or onleowner cle one) and have hired
the contractors listed below%vho have the fo11o•:ving, wor efs compensation policies:
-
Exrimtion Date
.yt- (Nnm of Contractor) (Insunnc; Corrll)anJ,'Policy Nulnbcr) ('.•,. )
(Name of COMT-IC10,) (Insurance Comrany/Pahm, Numb,--r) Date)
(Name of Contractor) (Insur-,Ulc� im.t:on Date)
(Name of Conti-actor) g suanc:. Comr,<:Iiy/Pohcy Ntunb-_r) (Lxpi.:tion Date)-
(atiJC3t additimil z1>`-ct ift:oce::,ry:n ix!•.uSc i::``.rvu[ia:��:ata:II�t::ell c-r:�adr:^)
i
l ) I Ian a Sole proprlc"m a 11Q havc no 0I1C "Vol king for m(e.
I am Il hoine 0�'![1C: l7CllOrining till L1C �'JOr': ia`rsclf
NOTE:plc:sc be atva:c that'.sl_ilc ca:-P;Iir—6-,
not tncee than throo units in alset he fsr vuirr raid73 cc oa t`_c thcrc(o n:e no(EcacrzllV
cnt-ployr:a un i-r tlwe tvorl a'a ar:y�sati n Act(GLI52-"1(5)),r.{ !:_:.'ic:i by a homcoc�m for n Lcrn c cr Pcr:t::: :-v r.': e
legal etxuu of en omployer under tLo wo,kcKj=Corn;xrnitkn
I under-a!-ad th,t a copy of t}v date rxr_t—y ba forwmrd d to tbo IY.parL--.f of Industrial AC66-y Ofl—of Luu.c>x for Lha
covcmgc vajEcalioc and flat fiilurc to raz(rc covcrngv undc-r scctioo 25A of M01,152 can Ic--d to tha inrnozition of mmin'.l pcnalf:cs
cooaisling of n fine of up to S 1500.00 a t 'nt i.prisona3c i
} n pn \V 01'_and a
find of S t00.00 it diy tF uml ar-
t _ Fcr dcr;u trrrlL�1 uic only
Permit N(tmtx r ---- _—
Si Gty� � 2 :11)"" Lot-------------- ----
� �ulturc of rill ttr c:
SECTO 8C1STRUCTION S:ERVICE S
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
- R�eetliW "m-e' emgn Not Applicable El
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...... ❑
UM OWR ,040'Un 4401% 4U ���
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, State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
a
SEC710N5DSGRIPTti0N0�FPROPOSEI �VVORK cti`ecktlna licable ' '
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Iff Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: Poo a1
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
say If Ne o se a�n�"d o a=dd"ifi.on to a fxe fx stirs k uo sing coM',bt the fo!°!MIM':
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 ''XOWNER AUTHORIZATION T0:BE COMPLETED WHEN
OWNERS AGENT,'{OR CONTRACTOR APPLIES-FORBUILDING!PERMIT
-;
ter§
1. as Owner of the subject property
hereby authorize � ti �e. 5 to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, ✓f�-- �-<-t 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.
�.fe.��1t.
�3 VS
Print Name
Signature of Owner/Agent Date — C7
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 I C9 0 1 3 /a a /3
Frontage
Setbacks Front //
Side L: R: L:y b R:_ /
O
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. A there any proposed changes to or additions of signs intended for the property?YES —
Nor
IF-YES, describe size, type and location:
City of NorthamptonS attas;v �
Building Department Cu a ✓t
212 Main Street Se r;Se
Room 100 Wa erIVV '
No MA 01060
0' '�-413.587.1240 Fax 413-587-1272
O�her�Spect, ��`h
APPLICATION TO CONSTRU6T, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section'to 6e p
com' l'eted bey office
1.1 Property Address, 4 �z
Map Lots Unit
Y ��ti G t�� Zone „OverlayDistrrct� s
C� �
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Rec d:
Name(Print) Current Mailing Address:
P
elephone
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 permit apphcant
1. Building (a) Building Permit Fee
3 cry
2 Ele;-� ica! (b) .Aimated Total Cost of
Construction from 6
I
3. Plumbing Building Permit Fee
4 Mechanica! (HVAC)
5. Fire Protection
6. Total = (l + 2 + 3 + 4 + 5) Check Humber p�V�
This Section For Official Use Only
Building Permit Number: .3 � Date Issued:
Signature: ------- ----- ------
Building Commissioner/Inspector of Buildings Date
File 4 BP-2003-1036
APPLICANT/CONTACT PERSON BUSHEY MICHAEL J&LOLA I
ADDRESS/PHONE 1070 BURTS PIT RD (413)586-9669 Q
PROPERTY LOCATION 1070 BURTS PIT RD
MAP 36 PARCEL 164 001 ZONE SR/WP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid M c;9,3'--
Typeof Construction: INSTALL 2 P ABOVE GORUND POOL
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE F OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commissi
� zvv
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
Bv�R Prc RDI BP-2003-1036
CIS#: COMMONWEALTH OF MASSACHUSETTS
' CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-1036
Project# JS-2003-1656
Est. Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 12022.56 Owner: BUSHEY MICHAEL J&LOLA I
Zoning: SP,/WP Applicant: BUSHEY MICHAEL 3 & LOLA I
AT. 1070 BURTS PIT RD
Applicant Address: Phone: Insurance:
1070 BURTS PIT RD (413) 586-9669 ()
FLORENCEMA01062 ISSUED ON.5123103 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 21' ABOVE GROUND POOL
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• Receipt No: Date Paid: Check No: Amount:
Building 5/23/03 0:00:00 1133 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo