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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 hds/her construction sups.,is 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 amt y
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 Wil ding department for the"City of Northampton wants-any person(s)-who-seek-tv -
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 your) 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
L 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
1
of {nrfll���t�fa�t
B E �t c�a�trllnsrtta•
DEPARTMEI-T OF DUIL.Dr)\-G INSPECTiOIds 1
j 212 Main Street Municipal Building
Northampton, D1ass. 010GO
«`OrtJ�LIt'S CONII'ENSATTON Ii tSURA-N CE AFITD�1.�'Z�'
I
(li ccnsxlperm�tttx}
\31rith a principal place of businesslresidence at: - -
" 'IV rG�'�C� (phone') je�
(szr=t/ci try/statcla p)
do hereby certify, under thc.p?jm :md penalties of per' , Ih i
a
{ ( ) I am an employer providing die following lworkces comocnsado, coverage i0f my
emplovees worong on tills job:
i
(Lnsur-� Compam') (Policy NiL=zbcr) — (::,piratior.D2=)
( ) I am a sole proprietor, general conu-actor or homeowner (CL',c:e one) and Dave hired
the COOD-actors listed below ryho hive the `ollowiL2 worker's compen—sation pakies:
I
I (i;=c Oi CO_tmcior) (In2rant Cotnoiz}vi'ouc; }�tLtrn�C:) (Y':J1rdL•?R(�ZtC}
(Name of Concaaor) (Ins-tuancc Come_anti•1po!ic; `umcrr) (YDirdop Daie)
(Name of Cot1a-aci&) Ozsuranec Compan y/pot-q- Number) (Expirrdoo Date)
j -
(Name of Contractor) (L>�suran� Compaay/Poticy Number) (Etpirdao Date).
(aC�[:1 �oci1 .it n�c�.--ti•cn c�du iaf«sv�oa pct.;niag to.Lt oxr-r_o:z)
Jf�C I am a sole proprietor and bane no one wort ng for me.
( ) I am.a home owner perforr=g all the work myself.
NOTE:pl=ic be cwNC ri.. +Je hemcrn vm ubp e=ploy pe_am to do cs e�aa c rte-oric o=.d%._U Z of
tux meet rhea t i-roe "teh the bomoowoe r=d-z«oa Lb c souarS zpputtev_.�tbe�n�M we�.r.Ry OL=.d-ni to be
�loyc-suze--the..vi r�---_, A, GUIS2-=1 S
(- � )).:.r^p[inaoo by s homcnana fc_Iirrc a pcmit r-7 cidmcr tM
legs!rt-
of= :pIGY_under do Woritdr ck a=:P oration Ae,
I saad dut a oopy-f tb:v cM1-=-ox my be to tb•Dcp_,t rs or job& d A�r...&OCG—or lr�ur+ooa I—tb-
eova� v-Zc=xioa and dut L-i t c to sa.-wt boverase undo so=ioa 25A of h(QL 13-1=Ind to the ia;9=i ioa of eimia%l pctulva
ooasi ag of a rMc oC UP to S 1500.00=zldfor azz{Sisoax of up to ooe ys=r cod c Nil p=A rY=in 6c form of a Slop Work Ord and
run of S 100.00 z riy LPICSl mc.
Lot
� for 6c-.s-,"•zz�u�c on77
e
tgnatu t of Lice-c_- Pr rrnittrr e
SECTION 8-CONSTRUCTION SERVICES •t
8.1 Licensed Construction Supervisor, - Not Applicable ❑ ..
Name of License Hold r: zo
License Nu er
Address / ar Expira on Dsfe
Signature Telephone
9Re`"isfere Come=fiin''teaveinerrECat►tracto'. -01 Not Applicable ❑
cZ eV
Company ime Registra iotiot -�I�u er ------
6L
Address Exp' tion ate
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVtT`(M.G L.c.=1°52,§,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...... ❑
' g • '
-1149M
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-vear 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)
a
New House Addition ❑:. Replacement Windows Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[O] Other
Brief Description of Proposed =f, j �,�._ /1,GL � �7�� O ale,
Work: r �
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
&a 1�Nevt€ �r"o�rse�rtd=a '�d�iQ�.,��:excst��c��.a�tslncr a eor�n�ete��he:�(a�>t�4:
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
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
SECTION 7a-OWNER AUTHORIZATION,,-TO.BE COMPLETED WHEN
OWNERS AGENT"OR CONTRACTOR APPLIES FQR BUILDING PERMIT
1, r - G �i xf as Owner of the subject
property `
hereby authorize 1'J "�- `��� (fl-)
to act on my behalf,in all matters elative to work authorized by this building permit application.
Si ature of Owner Date / IF5
as Owner/Authorized
Agent her by 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 o'Kperjury»
Y
Print Name
Signature of Owner/Agent Date
Section 4. ZONING All Informati6h 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 --
Side L: R: L R:r I
} 3
Rear
Building Height — -- -- -
Bldg.Square Footage -''---'_, % ; � I
Open Space Footage %
(Lot area minus bldg&paved --
parking)
#of Parking Spaces
Fill:
(volume*Location)
i
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
N0 0 DON'T KNOW YES Q
IF YES, date issued:;
IF YES: Was the permit recorded at the RR istry of Deeds?
NO 0 DONT KNOW VQ YES 0
IF YES: enter Book Page; and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 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:
E. Will the construction activity disturb(clearing,grading,a cavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 ,. NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of NortF ampton
Building Department
212 Main Streete m.
Room 100 eI r a a -- W
Northampton; AMA 01060 ra0p,
hone 413-587-1240 Fax 413-587-1272 PdoSt ans �
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be dompidtd bX office
t< -
_
Zone Overlay Distract
l
EIni. `Distrrct C13 District
SECTION 2-PROPERTY OWNERSHIPFAUTHORIZED'AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Addr
I
Telephone
X
ture
2.2 Authorized Agent:
Name Print Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED=CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed 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
This Section For Official Use Only
Date
Building;Permit Number. Issued:
Signature:
Building;Commissioner/Inspector of Buildings Date
25 BATES ST BP-2006-0676
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A- 127 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Catep,ory:Non structural interior renovations BUILDING PERMIT
Permit# BP-2006-0676
Project# JS-2006-0587
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Andrew Church 104480
Lot Size(sq. ft.): 11979.00 Owner: HILL ARTHUR B JR&AGATHA N
Zoning:URB Applicant: Andrew Church
AT. 25 BATES ST
Applicant Address: Phone: Insurance:
184 Spring St (413) 586-0918
FLORENCEMA01062 ISSUED ON:1212112005 0:00:00
TO PERFORM THE FOLLOWING WORK.-LINE EXISTING CHIMNEY SUPAFLUR LINER
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 12/21/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
25 BATES ST BP-2006-0676
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25A, 127 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:Non structural interior renovations BUILDING PERMIT
Permit# BP-2006-0676
Protect# JS-2006-0587
Est.Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Andrew Church 104480
Lot Size(sq. ft.): 11979.00 Owner: HILL ARTHUR B JR&AGATHA N
Zoning:URB Applicant. Andrew Church
AT. 25 BATES ST
Applicant Address: Phone: Insurance:
184 Spring St (413) 586-0918
FLORENCEMA01062 ISSUED ON.1212112005 0:00:00
TO PERFORM THE FOLLOWING WORK.-LINE EXISTING CHIMNEY SUPAFLUR LINER
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: 0(< 12130 l OS b"ts
THIS PERMIT MAY BE REVOKED BY THE CI Y OF NORTHAMPTON UPON VIOLAP,PN OF
ANY OF ITS RULES AND REGULATIONS. �,,��►
Certificate of Occupancy` z Si nature:
FeeType: Date Paid: Amount:
Building 12/21/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Cormvissioner-Anthony Patillo