36-185 pQ"�t1AMP�O
�l ASSACh1C8ltts
t
of Xarf4ainptarl,
Q-, DEPARTMENT OF BUILDING 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 has/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 foundationlfootings (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
-,J% MrT
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nf �lrz`flJ�tttr}Tfc1tt
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m DEP/'u2TMENT OF DUILDI?�G INSPECT'IONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMI TENISATION INSURANCE AFFFMA IT
----
v,,lth a principal plac,e of bllsiress/res eetice t:
- (StrceUCiC;I:;:a�:��gip)
Cl0 hereby CCriLI}-, 1!Il:' r L110 p<:!T1S 1'.117 pc n ,ILlcs 01 70:1711(}r, i.hF!C.
I an an eIIlplo}'ei- providing the iollov.,InL ' Ul"r;Cr`5 colIlnensaloll GOVeiaJC 'OF lily
0i11ployces wol-k--ing un t_lilJ fob:
(Insua._nc:: Compan�') (?c c-:,Number)
( j I am a sole proo;ietor, gentrral conk hor-teow0e7 (c c!e one) and lla':u hiree
the COritraCiOrS lISted below ivl t'-.,, tl.e 101 --pa;
!:o !: ^il:; ��orke s c�L: pen��on _ .es
Blame Of COnLMCto') RIn�`V i:C CCI ":'ir'�Gl1Cj Tvtt]iI1bri) �i :'sCi: D2tC)
(Name Of Cont:r-=,or) -- (7IlSI IP.C^ Com :I`iPe!ic; Nt rl r) (1 tioa Date)
(Flame of Contactor) (Ins! nc� Com,;an.;ii olio, NuJltrf r) x.ir do Date)
- (Name of Contactor) _ (Ins,:rmicz, Co1nr..:_yRolicr Numl;Lr) (F;:pi-!tio- Date)
1 11111 ': SUIC 111-Oj?rlO:Ui E'.:IQ ilr?VC I10 Oil's •:�U!-�i:i!y t0r :110.
I affil td 1101]10
?JO,IT::plcsc be Awa:c Ltsc.�.ilc txcco zr s t. c c: p!^+;x. -_ to dt n ';ut:c ct..: m cr
not neee th n[lace uuiu in t et r :
dzz c oc'`.V:r_:,�3 _r er�1 Lhcc c c xt fcrrall.i e, M
--mployc3 un.�rs tiv:vc:i:is cc z i;n;•.c:(C,1.!i2 --c?(5)) ic;;'oy s hnt:tco. rs:`ar a i ccu cc
lcgzl etatus of an a:tployx under tLlc Worker':
I undo_-s Land the-a copy oI!}v ctntcis•cuy to fof—%u!od to tit CY-j rL—re of Industrial A.n r t&Ot-j w of L•::"+r 7=a for tix
mvc--agc vcriG=ioc and t11 t U-urc to ra r co�cr�un -: c�,ic t 25A cf 1.101.152 can lc--d to t14 imposition c;cam^r_l pa aii s
oomisdng of a fur-of up to 51.S .CYJ a:t"'ov i--:tri Z_:,pf;:p Ln cr. }: e..1 e v l petal[a in do fcxrn eta S!c,';vni.Chu n:d
fr>r of 5100.00 a day agau;-1 m_.
- n For�i=,rv:nsi!ur crtl y I
Ji�nrtturc t>t :',tccll:;cJpr-rnl;;cr, ?�,
TWN 8 CONSTRUCTION SERVICES'
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder 71�o�C/, ^ /,� ��CMG 306
License Number
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�2 K Sitr� r1C (&Am/��6 /17
Address 0/0 (, Expiration Da e
52- :2 —uc>
Signature 7 Telephone
sty"e e� orrr mar memen ontracto Not Applicable ❑
Comfiny Name Registration Number
Address Expiration Date
Al 1131 11t,6 i`d" 1114 Telephone
'SES' J-1 WORKERS' COMPENSATION INSURANCE-rAFFIDAVIT(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...... ❑
a l F Jn
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"homeo,,vner" 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
x
SECTfO DS"°RT�ONOFAROPOSED�WORK check ail=a I�cab7e
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ) Other [ )
Brief Description of Proposed Work: Gof yi. t I L/-Ss /) p
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll D - Sheet D
6a�:fi :.ewe_"ouse. ora":dd tion toe Xisting hosing�co`mpl:ee the=follawl-g
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
SECI�ON7a� OWNER�AU�HORIZATION `TO BE COMPLETED WHEN
"OWNEkSA�EN10� CONTRACTORAPPLIES FOR BUILDING.PERMIT
as Owner of the subject property
P Y
hereby fithoriz q� to act on
my D�a gF&Ia s re tive 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 tame
Signature of Owner/Agent) Da e
i
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This colunm 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 S aces
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:
w
P
City of Northampton
Building Department
212 Main Street s
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE 4, O SH A ONE OR TW6 FAMILY DWELLING
MAR 2 1 2005 `}
SECTION 1-SITE INFORMATION DEPT Or 81!!I D 't iO!ig
r
l ufTIce
1.1 Property Address:
Zon _ �° OyerFay D�stncE `
U: l' 2 ;,Efrrtnitz ►�str[ct CRristnc % w
SECTION 2-!PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 O ner of Record: j
ame(Pri Current, ail . Ad
Telephone `
Signature
2.2 Authorized Agent:
Name(Print) ` 1 Current Mailing Address: Q=��
C" Te/✓vj
Signature Telephone U��Z
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building -� 3 (a) Buildina 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 = (I +2 +3 +4+ 5) Check Number
This Section°For OffieiahU"se-Ord
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
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898 BURTS PIT RD BP-2005-0893
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 185 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildinq
Category: BUILDING PERMIT
Permit# BP-2005-0893
Project# JS-2005-1239
Est.Cost: $2320.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sa. ft.): 31232.52 Owner: ERIKSEN HEIDI
Zoning: SR Applicant: DE Sheppard Roofing
AT: 898 BURTS PIT RD
Applicant Address: Phone: Insurance:
224 BERKSHIRE TRAIL (413) 587-0092 O
CUMMINGTONMA01026 ISSUED ON:3124105 0:00:00
TO PERFORM THE FOLLOWING WORK:REROOF OVER L 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 Occupant' Signature:
FeeType: Date Paid: Amount:
Building 3/24/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo