25A-085 Lzf-P of Xort4aillptan i=r
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DEPARTMENT OF BUILDIj\TG INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building �a
North unpton, MA 01060
>r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNM 108.3.4 to
act as i:is/her construction sup(:: , so r. 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
� r
understand the above.
(Home own 6r/resicjknt'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
��� ti U�If ) t7f 1C7J."fl cil)1 fDll
A �' f �Zasanrhnsrlla' _
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4 DEPARTMENT OF BUILDf\10 INSPECTIOI:S -
212 Alain Street Nfunieipal Building
Northampton, ATnss. 01000
'A'ORIQ:IZ'S CONTENSA`170 N -MSURANCF AFFMAVIT
(I1 CCIIStXJpCTmJ tICC)
nth a prblicipal plat-- of business/residence at
{phone-')
(sn-�.t/c�t`r/szaLCln p)
do hereby certify, under tic-pains and penalties of perJury, ---hi
( ) I am an employer providing isle followinL %vorkcr's comocnsZzio, cove zgc for Inv
emplovccs woriong on this job:
(Lamar-_a= Comte,) (Polic. Nu_ r) -- (E=:-pinion D,-t-)
( ) I am a sole proprietor, general contractor or homeowner (ccie one) and have hired
the conmactprs listed below ---rho have the foDoivjnp, worker's coo:Dtnsadon policies:
C-Inic of Co„^c-'or) (1t1R f1n CotnDJ,7)/PGUC; NLLM-I-C:)
(Name of CoacTzaor) Ras-d=c; Comoan-apobc-' \urnccr) (-Ekpirzaion Date)
(Name of Coaa-acid') (Lases-dnc�. Comparey/PoL-q- Nttmbj) (Expirdon Daic)
CN2MC of CoaIIaclor) (In_suranc-- Company/PoUcy Numbci) (Exp mdoa Datc).
(aaA,=]�:i�ocal�c�.il occti-s�_^y to nciuu inrormaE oa pctacaan6 a'U
ti
E
I am a sole proprietor and have no one worL-i-og for me.
I am a home owucr perforrnilig all the work myself.
NOTE:pl=-c be cw2rc tfi.•4-t-c 6cm ovvcra uto vx�Iay Vcwtss to cif ccs.c oo c r-cp=wcric on r d—Lb of
not mote th_n Lb--=t,j in-�Ch the bomoozwc raids«oc the p-ouocts tbe-r-n c.-c o=:d—d to be
cMPIO)e uade the—k=: -C=n;>- cci Aa(G L152 n 1(5)} :pplic 6=by a hommaac far c 6c=-.or p=rnn ray--rd—the
Icgzl CL-'L-of en C=Ployo under din wock,olr Gompom.azioo AcL
I •••,t•_•• d tba a Dopy of tbi.ml.®rm m..y be r«-•,.rordee to tSc Dcq„tmc�crind.+sn.J ncoea�ofyoe or 4s�+r.000 ror w.
ooYcr&b'e`'c'irczIioo=id thi t-iltzt to Lc==L'o�-cr tmd� section 23 of MQL 152 eta Imd to the of eiminal Po°' m
eoosizmg or a twe orup to S 1 Soo.00 ardor ir�e of up to ooe yc3r Lod 6vu pmiltio in rsc form of a stop wort;Ord--and a
firms o(:S 100.00 a tL•y tgxia me
Fa dcputrn��u,c only .
Lot
e .J
r9natun of Li�lPccmiucc -
SECTION B-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
9`Fteiiisterced.Haine ImpFQ"veinent,Cnrifracor *-��-���.,, ��-_ _
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§25C(S))
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 faun
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,State1 and Local Zoning Laws and State of Massachusetts General Laws Annotated.
` �omeowner Signature '
V
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[0] Other[0]
Brief De ription of Proposed / )
Work: r'� �+!1r>
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
s°a,tfiNew;�louse�an� ��d�itor tomexr���ia��i usina;�-cornpiet�tt"e�o`t[ovuTn'A:
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
1. 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
SECT,ION-7a�=-OWNER. HORIZATION--TO BE COMPLETED-WF- EN-
OWNERS AGENT OR k"CONTRACTOR=APPLIES FOR,BUILDING PERMIT
l as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I 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.
Pri Name
Signature of Ow06NAgent ' Date
=
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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 7--j %
Open Space Footage %
(Lot area minus bIdg&paved
#of Parking Spaces
(volume&Location)
A. Has Special Perm it/Variance/Fi nding ever been issued for/on the site?
NO \���� D0N7KNOW \_��� YES ^_���
IF YES, date issue&
�
IF YES: Was the permit recorded at the Registry of Deeds?
NO ~~~[ � DON7KNOVV 0 YES
IF YES: * enter Book Pogo| and/or Dooumont#
�� �� ��
B. Does the site contain a brook' body of water urvvet|ands? NO \_� DON7 KNOW �~� YES ��/
IF YES, has permit been ur need tobe obtained from the Conservation Commission?
Needs tobeobtainmd /—� Obtained �-~�\ Date\~� � '
C. Do any signs exist onthe property?y? YE8 \_� NO v~�
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 .grading,excavation,or filling)over 1 acre oris it part ofo common plan
that will disturb over 1acre? YEG ���) NO � )
��
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
•
fi Departrnenlnuse only.
City of Northampton Statusa3olc' �� �� � "
Buildin g Department
De k
p
212 Main Street ca� Se ,tab � �
Room 100
"^ Northampton, MA 01060 �r ansY
phone 413-587-1240 Fax 413-587-1272
4_ k
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION-11 -SITE INFORMATION
1 Property Address: t This sectian to'156"!completed by offices
�i.�'�� �,^/��� St�✓��� s�Vlamp �otf ; sw U�
of i�f` sJ1 Gl /Y1 7 i.�) 17 �1 f Zone Overlay Distr�cE
0A) EIm St istrrcY '' ` GB Dastr�ct
SECTION-2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: rl
N me(Print) , Current Mailing Address: /
4'1.-s-
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 1-ESTIMATED'CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com leted by ermit applicant
1. Building -,(a)Building 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=(1 +2+3+4+5) Check Number p� Q
This;Sectionfor Official"Use Only
Building Permit Number.. Date .
Issued:
Signature:
Building Commissionedlnspector of Buildings Date
359 BRIDGE ST BP-2007-0484
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A-085 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Perrait: Buildin4 DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2007-0484
Project# JS-2007-000706
Est. Cost: $50.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 22781.88 Owner: NESTOR CAROLYN J
Zoning: LJRB Applicant: NESTOR CAROLYN J
AT. 359 BRIDGE ST
Applicant Address: Phone: Insurance:
237 PEARL ST O 536-5549 O
SOUTH HADLEYMA01075 ISSUED ON:1012612006 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE GARAGE ROOF & POUR
CONCRETE FLOOR
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 10/26/2006 0:00:00 $50.002866
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo