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DEPARTMENT OF BUILDI\G INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supc.-,"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
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
z m UEF'fu2"IMEN7 OF BUILDING INSPECTIONS
212 Main Street ' Municipal Duilding
Northampton, Mass. 01060
NVORICER'S COMI TENSATION INSTJ1ZANCE A AVI.T
v"Ith a principal place of btilsiress/re:, denc t'.
f`phOnC�=�'
(10 hercb}' CCr71i}', UI1C'ti1- 111C p ms and peil it1CS 01 pCr�l1(�t, t11Pt
] am an clllplo}reI provicim-, the iollcv,, :: '':<')rt_Cr 'S colny)cnszLoll coVCr21-l'+" !Or lIly
employees working on this job:
(I==oa Company) (Pc;;c,Number) ---- (ra piraacn Date)
( } r = a sole proorittor, general c..onn-=-or or 'r10 7leo��-ner (circle 0126 and lave hired
the contractors liste;l beio ,to is the oll :; ,;T-orners co pensi on of cies;
(N=c of Cmumc-Or) (Trifu7: ncc l.vI?1^?'i"t r�'G!IL f Tvit11 i1�Ci) 11,1-xT,, m!iGP. Datc)
(Name of Con (Evp. atio on dare)
(Name of Contractor) %Lo; once Cou;;:�n}�r ol;�. Nmi�ff�r) (-.xi,:r�doa Date)
- (Name of ConInctor)� (T=,T uc.'. Coim .y Policy Nu.ml;:r) Dare)-
(e!LaGI:�"i,tlOr:11
SoIC Eii'd hL","C 110 7E?C ,I,.
all a l:ome OCT:C-IIllp a!1
not[mce th_a throo units in wL-d+t ie E;;ti> .tzr rc: :u «;u v`•::� cr_ L cc e c o-i cerssll-i
c.".pIoycs%3nec t1x wv 6-,cts CC^;--:a:icn Act((iL:52 c1(51';.:+:iic:'ic:;Lv a hocnron xr fcr z Lccu cr p:ra:i:: n c L-
Icgal ctatua of an empIoyer under t::o Wo kc,'i o ;m iiian!.cL
I uncle stand thL a copy of thi,crate r•c:iy b, fawn u�J to v o[Y.t u tzu of Ioc:v_=icl Aci--&US of;: `_4 for Lox
covcr&&c vaifiGtioa and that f:ilttrc to 25A cd MGL,152 can lc--d to Qx i-:PoiitiOn o"
comialmg ofa fur_of up to S 1-5CCI,Luj of;:p to rr.-}t... ..-d civil xrultics in�c fc,nn cf n S!r:''��''TZ.- - =•^�
Lra oCSIOdAO I day Dais.,m:.
Fcr dq uut>z[s1 uic only
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SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : /�`(L&, CS CS-119 z.
License Numb r
Address C�.. Expiration Date
r e1 —
ignature Telephone
tare � m n C a M Not Applicable ❑
Company Name ,r� �J � Registration Number
�W 7-2��yn(1z I 1--,) C,4
Addr Exphticfn Date
Telephoned—� l
SECTION 10 WORKERS' COMPENSATION INS,URANCErAFFIDAVIT(M:G.L.,c. 152, § 25C(6))
3,:.
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 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
SECTION 5 IDES - t�ON�OFPROPOSED 41IORKtv(check all aPplica6le)
R, ,. _ & r
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolitiorilid, New Signs [ ] Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: km,a/c &.,p4rippP I-,(-
Alteration of existing bedroom Yes bC No Adding new bedroom_ Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll❑ .Sheet❑
a°nd or adVition to ezistin :housi'ng complete the followr
a. Use of building : One Family �G_ 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 .
1. Septic Tank City Sewer Private well City water Supply
SECTIdT 1►NER,AUUTHORIZAT101� TQ BE COMPLETED WHEN
01NNfS gENTUORCONTRACTOR APPLIES,FOR BUILDING PERMIT
Jac as Owner of the subject property
hereby authoriz /�(. C�O� zcr�DF s Z4 C, 4C—Z_ KLei2ciL to act on
my n all ma ers relative to work authorized by this building permit app.!ica ion.
�
S wne D to
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.
lrNt `.� 71�- �lEIL�2C)C)�
Print Name
Signature of Owner/Agen Date
�I
` I
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
i
i
Lot Size
i
Frontage
i
Setbacks Front
i
Side L: R: L: R:
Rear
Building Height
i
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 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT 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:
y of Northampton
60 ding Department
004 W'Main Street
R`l Room 100 fi
Northamp n, MA 01060
phone 4,13,-587-12 0 Fax 4l3-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This secfioa fio be completed'by office
1.1 Property Address:
eY ��� Mai Lo
L--.4-co _ Uhf
done" � Overlay Uishacfi : x .
zrrrr
fi,�EEm St�D�stnCt °rh _ C8°DisMct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pr' t) Current Mailing Address:
p
Telephone { i
Signatu _/`�
2.2 Authorized Agent:
NamZ'4w Current Mailing Address:
(,
X14 f � f✓r 1
Si66ature Telephone
SECTION 3—ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use.Only
completed by ermit applicant
1. -Bti>'tdin ja)Bullding�Permit;Fee
g 3 Cb#OL /77lX,y
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 On"ly__
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-1099
APPLICANT/CONTACT PERSON MICHAEL PHILBROOK
ADDRESS/PHONE 242 RESERVOIR',RD WESTHAMPTON (413)529-1819
PROPERTY LOCATION 55 WINTERBER.RY LANE
MAP 36 PARCEL 205 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid c
Typeof Construction: REMOVE WATER DAMAGED FLOORING&SHEETROCK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 051892
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9k64ATION 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 Co sion
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.
f
55 WINTERBERRY LANE BP-2004-1099
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-205 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-1099
Project# IS-2004-1638
Est.Cost: $7500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MICHAEL PHILBROOK 051892
Lot Size(sq. ft.): 55756.80 Owner: JOYCE PATRICK J&TERRY A
Zoning: SR Applicant: MICHAEL PHILBROOK
AT. 55 WINTERBERRY LANE
Applicant Address: Phone: Insurance:
242 RESERVOIR RD (413)529-1819
WESTHAMPTON MAO 1027-9613 ISSUED ON.517104 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE WATER DAMAGED FLOORING &
SHEETROCK
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 5/7/04 0:00:00 1224 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
55 WINTERI•.. BP-2004-1099
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-205 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit# BP-2004-1099
Project# 35-2004-1638
Est.Cost: $7500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: MICHAEL PHILBROOK 051892.
Lot Size(sq.ft.): 55756.80 Owner: JOYCE PATRICK J&TERRY A
7.onin-: SR Acv 1p icant: MICHAEL PHILBROOK
AT: 55 WINTERBERRY LANE
Applicant Address: Phone: Insurance:
242 RESERVOIR RD _ (413) 529-1819
WESTHAMPTONMA01027-9613 ISSUED ON:517104 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMOVE WATER DAMAGED FLOORING &
SHEETROCK
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:
Slit 41sliNtic s..:
Final: Smoke: Final: /�, 7
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.Cer tificate of Occupancy si nature: = ��
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 5/7/04 0:00:00 1224 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo