36-188 (2) Cr zty of Wort4ampton z
$ $ �'dassacf�usetfs `'
� DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building '>e
1y
Northampton,MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as l:is/her construction sups.r•,J,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 fami
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 depart nt for e City of Northampton wants.a y erson(s)who seek to
use the home own exemption. o act as their own constructi supervisor,to be aware
that by doing so you become resp Bible for compliance�iilding h state building codes
and fegulations. The inspection pro ess requires that the department be called
to inspect work at various stages, whic include foundation/footings (before backfill),
sonotube holes before pour), a rou h uildine ins tion before work is
concealed insulation inspection if re fired and ifinal building inspection. The
building department requires these inspects .is beftain the work is concealed,failure to
secure these ins ections can result in failu a to a certificate of occupancy
until the work can be inspected.
If the homeowner hires other trades to perfor ork(electrical, plumbing& gas) the
homeowner will be responsible to make sur that a trades hired secure their proper
permits in conjunction to the building per it issue and that they get their required
inspections. Failure of the individual tr es to secure he permits and inspections as
required can DELAY the project until uch time as the per 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 f the building permit
issued to me.
Date
Address of work
location
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DEPARTMENT OP DUILDf)\C INSPPC7i01.'S
212 ?thin Strcct Municipal Building
Northampton, Mass. 01060
«VORig:R'S COi\ PENSATTON GgSURATNCF AI FMr VI-17
(li c>rusxl permi lice)
\vuh a principal place of businessfresidence at: - r, --
2 �J (`S I �L (IK �� `UlLi/�� (phone..
(s�-�-t1ci ty/siatcta P)
do hereby certify, under dic.pa_ins _and penalties of pc9wy, :hat
( ) I am an employer providing the followIM-11worker's comocnsaoon cove ale for illy
emplovices worLong on ties job:
I -
(Insut-:_n=Coax c.) (Potic:Numbccr) (=:pirnor,Dzlc)
( ) I am a sole proor;etor, general contractor or homeow-Der (ci c:e one) anti have hired
the coaiTaCors listed below wbo Have the following workers c,=DenL-aeon pe!icies:
i
(i+am Oi Co-`.t::lczor) (InR!rancx. Cornpany/hOUCi NL1ffLCI) (i;)Inn:cn bate)
(Name of Contrctor) (insaran CompaawPotic}, Nuimc_r) (L:D-m6on Date)
(Name of Conn-actor) Onsuranc Compan}'/Polk}- Na mbzr) (Expir.:600 Datc)
I -
(Name of Contractor) (Losuranc-c Compauy/Policy Numbs) (Expim6oa Date).
(aa2jcb sd i-:Ccal 6cd,ifneocza_-v to 6cur4 informa=ioa pcztainin.s to all ooasso:�) -
am_a sole proprietor and have no one woriong for me.
( ) I am,a home owner perfon=g all the work myself.
NOTE:pt==be ew-uc tfi. M1 JC hcc=d *cn V bo aarrlay pC1o=to do =—=,Do c rc,air walk ca i d%%mU-Z of
ant tnoce then tts r a in inch the bomoo-ur raid.oc oa the V=,d,zppurteatct tbceo a.-e ooc occrdaod to LY
ca
--tploy antic the Mal dz --,:�qar(GLtI5Z=1(5)),applintioa by a bomco%-=f=c 6c=%c or permfr rr_y a-idcooc ebe
Iegal clams or an¢;Iloyet under dto Wocfr o--Compm.xion,tic.
I unde+twd the a Dopy of thin may ba foc..nr d.d to tbo orynrrmaot of In&arriJ Acted my office or uw ooa fx t6.
covcraSc*�C31ioa and th_i f_ilLm to r.oatrc bovcrngc tmdcr to joc 23 A of MGL 152 m lc.d to the i=POS 0a of aim7n pca+Wv
ooaaiSmg of a Soo of up to S 1300.00 wwcc i= iyoanxi of up to Doc)ur ead aril pauhia in 6-form of a Stop Work Ord-and■
f=of S 100.00 a d_y aty;na tnc
For ---
PcrMit NUML—cr
1`'t3 P- ---Lot.'
Sigta(um of Li crrrxiucc e .J
SECTION,8-CONSTRUCTION SERVICES
_8.1 Licensed Construction Supervis-^{o'r� Not Applicable ❑
Name of License Holder:
License Number
Address 0(b,2,6 Expi a it of n Date
Sigma Telephone
9tegis ere Mme piovme *onto'' o ` NotApplicabie ❑
16�-
Company Name Registration-Num er
Address lw � �-��.J D Expirat not Da et
Telephone
SECTION 10-WORKERS'COMPEN2ATI6N INSURANCE AFFIDAVIT(M:G:L c.152,.§26C(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....... 1K 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 1083.5.1.
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 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
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
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SECTION'5--DESCRIPTION OF PROPOSED WORK(chedk-alLauOlicable)
New House [-1 Addition ❑.": Replacement Windows Alteration(s) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[O]
Brief Description of Proposed
Work: C/ � % /• ""�lY)( %M A..-' •x
Alteration of existing bedroom Yes No Adding new bedroom Yes No -
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sf teiouse Ga eclt>� # 1 #ni ° sinner cuiatefit40 u:ii:
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
_ g.,-
OWNERS AGENT.QR too TRACTQ 4PPL1 R.BUIL.�DI,NG PERMlT
as�Ow Owner of the subject
property n
hereby authorized f , Y/
to act on my behalf,in a matters relative to work authorized by this buildin it application.
Signature of Owner Date
7andas Ownn t A__._o� ed t hereby declare th the statements and information on the foregoing application are true and accurate,to the best of my knowledge
elief.
Signed under the pains and penalties of perjury.
Print Name
b �
Sigr6We of O r/Age Date
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Section 4. ZONING All Informati6h 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 s I
Setbacks Frontf
Side Ll R:- U R:I 4
Rear U
Building Height "' '' -
Bldg.Square Footage % ( r
Open Space Footage % �---
(Lot area minus bldg&paved
azkin
#of Parking Spaces i
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:; [
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book j Page} and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 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 I Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 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 I
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
I g Department
CQ c 1'2 Main Street
Room 1,,00
North pton; MA 01060 '
OCT 1 i2o13- h240 Fax
413-587-1272
ApPLICik'nb! n,6l s"+RUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION.1-SITE WFORMATION"
Th�ssection to�e completed 6�gff%ce
1.1 Property Address:
Overlay Dis�ct s
,. . Elm S D°strtct.. ..... 4
C8 D°stnct
SECTION,2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
N e(Print - ent Mailing Address:
,� - - Telephone
Signature
2.2 Authorized Agent: �� I":�� "��
Name(Print) Current Mailing Address: �}
Signat 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 (li)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 Onl
Data,,
Building Permit Number Issued:
Signature:
Buildings Commissioner/Inspector of Buildings Date
856 BURTS'PIT RD BP-2005-0449
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 188 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0449
Project# JS-2005-0596
Est.Cost: $2850.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sc.ft.): 74923.20 Owner: MOORE KENNETH R&
Zoning: SR Applicant. DE Sheppard Roofing
AT. 856 BURTS PIT RD
Applicant Address: Phone: Insurance:
224 BERKSHIRE TRAIL (413) 587-0092 (�
CUMMINGTONMA01026 ISSUED ON:10118104 0:00:00
TO PERFORM THE FOLLOWING WORK.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 Sienature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 10/18/04 0:00:00 545 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo