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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 780CMR 108.3.4 to
act aS 1:is/her construction supc_. „sor. T he 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
tainspect work a ious-stages, which_include-_fQundationLf�aotin s_(before backfill),
sonotube holes (before pour), a rouLyh buildinL 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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F e (rIL-�) of k{ortllulliptall
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OEPARTI.IETJT OP BUI LID r,\,C INSPPCTIONS
212 Alain Street Municipal Building
Northampton, Mass. 01060
«`O R1Q;R'S COO P`v N S A`IT O N •INS"URAN CF Al'I'D�A VIT
01 ccUSxJpermJ acc)
\kritb a prulcipal place of business/residencc at:
76 ��r� ��.��.; ,2o ,ea�,�,�� �'. , �. (phone;=}
(sn r t/ci ty/a2_tc z:i P)
do hereby ccrdi .-, under thc.pairS and penalties of pcgury, 121
(X� I am an employer providing the followine %vorlcer's comocrisabo, coverv�e for Iny
etupioyees worng on this job:
-7 f 74-R-_77S_71'3,37- 2(,107
(I.asur-_an= Conran}-) Tclicr Nuabcr)
( } I am a sole proprieror, general contractor or homeow_oer (circle one) and hive hired
the conuactors listed below vqbo have the following worker's cooaen_saaon policies:
(,Namc Oi CO^'^1ci0r) (lll_-,!ral1C.^. COIIlOy'1}'rPGUCi NtuJSl=<l)
(Name of Coccraeior) (Insuzncc. Comoan-wPol m Nuncfr) (-Expirz6oa Date)
(Name of Coaincio.) (Insurance Compan}•/Palle• Number) (Expirdon Datc)
('Name of Concraeior) (Insurance Company/Policy Numbcr) (Expirtioa Datc).
(.rich-�6,=oczl cSca.rncrcz��-to ccu� af«m�oa pccainins o.11 oo�-coz)
{ ) I am a sole proprietor aad have no one work-ing for me.
( } I am.a home owner perforrniag all the work myself.
NOTE:ple be avnrc ri— 1:Je hemcowacra vtip employ per,w LSa rr-e ro c c ca�orX ao.d.•c1L:�of
aot mccz th=LL111a in winch the bomnovVncr raider or oa the gvjjc f,i puttcn_r�tbc•ro c.-c oue e•�.rlty oea:daoj 10 tr
rstpior-s tanc e the Act(G Ll 52:3 l(5)�pgIi=6=by n bomcoave fcr n L e�-or permit tzy n-i�the
IegoJ rtX^,•of as acMPloyor=d.er dan W06-o L Coosp000..iao Act
l undc:ia.nd d1.a a oopy of tbi.-w--i may b<f---,,i-d to tho Dcqutimcos oCin�azuiJ/l dca&Offioo of 1,�r.00a ror tho
oovcrxsc vaTic3 ion-ad th:s U-=h c to scoirc)cove..&,, 60Q 23A of MGL 152 era Icd to the in�X'tti m of criminal Pzn cs
maLL::!2g or a riac oCup to S 1}00.00 and/or oCup to ooc ycar and ciao pca l-.ia in 6c form of a Stop Wort ordc and a
Gm 0(5100.00 a d_y�piaA me
P° ---Lot ," R.
Sipmaturc,of Licznscclperrniucc �� /
SECTION 8--CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder: d'�u.✓Q �/ �£�'���� t12 Y-06,
License Number
76 %4.ti'C.?oC'r /c'r? /�(02'�7�m"-�./, .w✓-1 , � �1��y�
Address Expiration Date
Signature Telephone
9._12ediste'icd'1{ometlmaFarieieriottractoc: Not Applicable ❑
Company Name Registration Number
al",/
Address Expiration Date
,rr-an/ Telephone V19- &'5S'36!
SECTION 10=WORKERS'COMPENSATION INSURANCEAFFIDA-VIT' M.GL..c-f52,-§-25C(%)
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-o-wn-a-parcel-ofland 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-<DESCRIPTION.OF PROPOSED,WORK(check all applicable)
New House F-� Addition 0 Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [ED] Decks [Q Siding [0] Other
Brief Description of Proposed
Work: te2�7/.�c
Alteration of existing bedroom Yes K No Adding new bedroom Yes X No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
t;a` t�'�CeW��i`ouse�;amforc�"ct�ai>w�'�excstf�ng�hous 11�g�cai�g; t ��i���if[�i €[:
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
L 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
SEC- ,,ION 7a=•OWNERAtUK RIZATION:t()BECEQMP_DETED WHEN-
OWNERS AGENT-OR CONTRACTOR APPLIES.FOR°°,BUILDING-PERMIT
as Owner of the subject
property
hereby authorize
to act oney behalf, in all matters rel a to work authorized by this building permit application.
Signatu of Owner V Date
as&per/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.
l-do< d E /i✓r
4,J
Print Name
Signature of- /Agent Date
^
'
Section 4. ZONING All Information 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
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Variance/Fi ndi ever been issued for/on the site?
�� ��
NO \_��� DON7 VV v��KNOW YES �~�
IF YES, date issued:
IF YES: Was the permit recorded at the Registry o[Deeds?
NO ~-^C � DO NT KNOW
IF YES: enter Book Page and/or Dooument# '
�� ��
B. Does the site contain a brook, body of water or wetlands? NO ����/ DON7 KNOW �_� YES \��
IF YES, has permit been or need tube obtained from the Conservation Commission?
Needs tobmobtained �~� Obtained �~\ 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 toor additions o[signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre oriait part o[a common plan
that will disturb over 1acre? YES [��l NO ���)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Depart%nerttrrt�re�tl �" `
Wj
City of Northampton
Building Departmentnr�e
212 Main Street sew ec epanii ,
Room 100a
Northampton, MA 01060 �te� ra ��
-1272 phd 0e 413-587-1240 Fax 413-587 . s
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1.-SITE INFORMATION;
_ mp[eted by affice
This section<.to-6e co
1.1 Property Address:
IVlap Lot UnFt
Zoie Overlay Destruct
t-
ErI Distract CB�RistncY
SECTfON:2,-PROPERTY OWNERSHIPIAUT.H.ORIZED A GIENT'
2.1 Owner of Record: / Lf
_.LiC".61/� dLL _/ �L�/`.✓ ?�jc�f'.r� ,�4.+/�', {ai's:-✓C�. M✓�.
Name(Print) Current Mailing Address:
TZ/ a
Telephone
nature
2.2 Authorized Agent:
r�1/N i��� 7 �3 /�.A,�_c�r 9 r="T i��• �arc`rH.g-
Name(Print) Current Mailing Address:
Signature Telephone
SECTION-11-ESTIMATED`CONSTRUCTTON=COST,S
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building O o� '-(a)•Buil'ding Permit Fee
2. Electrical ------ (by,.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 V
This.Section:For-Official Use Only
Date
Building;Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
43 WINTERBERRY LANE BP-2007-0607
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36-202 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-2007-0607
Project# JS-2007-000893
Est. Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ED LENNIHAN 105618
Lot Size(sq.ft.): 86248.80 Owner: VOLZ BRUCE&SARAH G PRINGLE
Zoning: SR Applicant: ED LENNIHAN
AT. 43 WINTERBERRY LANE
Applicant Address: Phone: Insurance:
76 Bancroft Road 587-0437 WC
NorthamptonMA01060 ISSUED ON.1112912006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR & RECONSTRUCT EXTERIOR
CHIMNEY
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 11/29/2006 0:00:00 $25.003846
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
43 WINTERBERRY LANE, BP-2007-0607
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36-202 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-2007-0607
Project# JS-2007-000893
Est. Cost:$2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grouh: ED LENNIHAN 105618
Lot Sizes . ft.): 86248.80 Owner: VOLZ BRUCE&SARAH G PRINGLE
Zonis::S Applicant: ED LENNIHAN
LANZ
Applicant Address_ Phone: Insurance:
76 Bancroft Road 587-0437 WC
Northampton MAO 1060 ISSUED ON:1112912006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR & RECONSTRUCT EXTERIOR
CHIMNEY
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:
Final: Smoke: Final: CK I-9-074A"
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupanc _ Sienature:
FeeType; Date Paid: Amount:
Building 11/29/2006 0:00:00 $25.003846
212 Main Street,Phone(413)587-1240,Pax: (413) 587-1272
Building Commissioner-Anthony Patillo