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{y DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
North,arnpton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction super,, .or. 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
' O fib `1•' _.
Glip of NTI.Iri:ljalllpft1II
� 6 ;ilcsaRC}Insrlts
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m
DEPARTMENT OF' 13UILDII�G INSPECTIONS
212 Main Street ' Municipal Bui! rig
2'Torthampton, Mass. 01060
WORKER'S COli TENSA'MN INSURANCE k FEDAVIT
----- / (liens°Jrrrnlittcc)
principal place. of busirlesslr :idenc
._(T h o fie ------67
do hercby =-DINT LIIC'til th1 p<_ins -iilcl pC:i1 1j'L
( ) I am an employer providing the Iollovvi;-: : v.ork_cr's cornllerls�lion coverave For In),
employees worl.-,ing on this job:
(Inq=c-� Corapam') / (P c-ii c;Nu:-Lbcr) (ExTirtion Date)
l ) I am a sole proprietor yrentra s (cicle one) and 1--ve hirt--d
the COP.tTaGfOFS LISteC be.o� the tot :Y'i : ' JOriterS COC peIl4 O11 no!;ClcS:
/V --- -
(- amc of C0!1tmclor) ('LnS'=mnC ?::'rv.f o-i D<tc)
(Name of Contractor) Omsun ncc Co r_ vtPc!ic N 1 1 t. r) (l xp tioa D2te)
(Name of Contractor) (lr>;tr s1Ce {_Oil7 ;'_il:i%t o!;Cr' NL]I;11%7) ti,'i«i10 Datc)
- (Name of Contrlctcr) —- (It1suranc Coin y i oticy ltitum *)
( 1 ani it "�ol(; propric"ol- illl(1 h vG no OIl OC^;liiE� 101 nle-
I ?111 2 ti:011?c O'vnc i)Lr_'o-.In
NO"IFi_plc c Lc n>z c tlst s1:iJc It<uo>;r s« -s r, L .;>.. ;ti r_vlrsaacc a:.:� =m cr
not tzlcYe ih:o thrcc uuiU in tti::ctt•hc 1:�;:-.�.u-t,�res:�.�a•a;::>.:�;�_;,'3 z urtcr_r1 Lhcctc z:c tr�t�crr�l2y ar.:'t::::�:o tk
c rploycs un-'cs t}v tvo,xis ar z•�: icc,ts ((ii.!S2 !(Sl;;,a,:;lic:tia:by z l ptnron xs`:or z L"='x cc pcsa:i:::- C.-
Icga1 status of nn crrployer undrr tt:�Wcvi cl.Ca.��m_-iiion�,ci
I undc stand thL i copy of this ctatcis•cvy bo fot w tod to tt» Off)— for ttx
oovCr-&&vaiftc:tioa and taut C_ilurc to to c c0"--r_3 ur c:�C.i r 25 A of?.tG1.152 stn It--d to tlx imj ositio c =i_1 pail u
Komi-%mg or a rm,of up to S 1.500.0-0 vl&'nr of::p to cr..}- r:.l civil perulticz in d.c is rrn of a SIc-,l Otis zr'd z
f:rsc of!;100.00 a dsy
For 6�uatr"j urc c.tly
T ._,,, _ F
5t�naturc of I.iccn cJI'ctnlittce
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SECTION 85 CONSTRUCTION SERVICES'
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : TAf ' Z�2!A, b O 7
License Number
Address Expiration ate
Signature Telephone
�- Reg s e e 'om m'o ouem'enf'Gontractor- -- ��m
Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SEGTION 10 WORKERS'-COMPENSATION INSl1RANCE AFFIDAVIT(M,G.1. o. 152, § 25C(6))
r ,.,.
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 _
" � 3�ikrc�� F'}' � � ^aP att»a^• sb'.;fK . �
SECTION= S. R PT�ON QV-P OPOSED WORK check if lica le �
T.`0
.ii,
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ` Demolition❑ New Signs [ ] Decks
[ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: 13v I Ls> 1,0 'J (`k S N e p e SL
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
a.. =Mew,Ous a `d:�or a. d tion:to.ezistin .h uo srn'`�cotn e fhe followin
g"" g p
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. bimensions
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
SECTIOhI�a-OVYNER� UHORIZATION TO BECOMPLETED WHEN
OWNERSAGENOR CONTRACTOR APPLIES FOR BUILDING=PERMIT
I, lq S KN N fj7� as Owner of the subject property
hereby authorize to ac, on
my behalf, in all matters relative to work authorizz by this building permit application.
�-- ytc�-b y L
Signature of Owner Date
co n it-e P 7-0 WrVE- fir/.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 Name
Signature of Owner/Agent Date �—
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
Frontage
Setbacks Front 3 p
Side 30 L: R: L: 32 R: 3 �1,
Rear 30
Building Height
Bldg. Square Footage 1 %
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 —X
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:
OTINorthampton
Department
i Main Street
APR - 9 2004 I .R om 100
Northern ton, MA 01060 .
- phone 413-587- 240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 sr m INFORMATION
x This sechoato be camp[eted ofRce
1.1 Property Address: t A
9 L} Map a
a Zone " Overlajr D�sbact
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED.AGENT
2.1 Owner of Record:
me(pant Current Mailing Address:
Y2 G� Telephone
Signature
2,2 Authorized Agent:
Name(Print) Current Mailing Address:
Signer a Telephone oZ
SECTION 3- ESTIMATED CONSTRUCTION COSTS,
Item Estimated Cost(Dollars)to be Offidal.Use,Only
completed bT permit applicant
1. Building ,1 4 U (a) Building Permit Fee
2. Electrical "i (b) Estimated-Total Cost of
Sti Construction from 6
3. Plumbing Bullding'Permit`Fee
4. Mechanical (HVAC) Z
5. Fire Protection
6. Total= (1 + 2+ 3+4+ 5) a5O Check Number �` -7 9
This Section For.Official Use Onl
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
294 CARDINAL WAY-LOT C BP-2004-0984
GIS#: COMMONWEALTH OF MASSACHUSETTS
MU:Block: 36-304 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: shed BUILDING PERMIT
Permit# BP-2004-0984
Project# IS-2003-1669
Est.Cost: $4250.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: THEODORE D TOWNE
Lot Size(ssq. ft.): Owner: MIRANDA THOMAS A&
Zoning: SR Applicant: THEODORE D TOWNE
AT. 294 CARDINAL WAY - LOT C
Applicant Address: Phone: Insurance:
67 DIVISION ST (413) 527-9060
EASTHAMPTONMA01027 ISSUED ON.
TO PERFORM THE FOLLOWING WORK.-erect 10 x 14 shed on slab
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 4/13/04 0:00:00 7989 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo