25A-127 (5) Pb
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building
Nortluunpton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction sup(.:-:isor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two farm
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
4 understand the above.
(H eom 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 _ d
location - l / 4 ± �
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Crii� 1�f �nrfl�ani}�foli -
31 a 3 cf,nrc(1's
4 o DEPARTMENT OP BUILDING INSPf'CTIO1.'S I
212 Main Strcct Municipal Building
Northampton, Mass. 01060
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«`OR1tI:IZ'S CO�ff'I;NS�TION MSURA�CE :�I FMA.ATi-l"
I
(Ii CCn&cc/PcrMj ticc)
k ith a pRncipal place of bisiness/residencc at: --
do hereby certifj under d c.palns and penalties of perjury, hai
( ) I am an employer proAding the follo.ving %vorkcr's compcnsabon cove�gc 'or Im
emplovees worUng on Lilis job.
(Iravran=Coara ) (Policy Nu.mhcr) (r;piraaor, Da -)
( ) I am a sole proprietor, general cona-acior or homeowner (ci c:e one) and have hired
the conu-actors listed below who h2ve the fokwinQ worker's comnen_sat'on pc!icies
(i+QIDC of ContT71acr) Gr1R!ranc:_ Co(npari)-/PoUc-,• NIUM-<:) -- (Y_?;Jlaluo?Datc)
i
(Name of Coac-aclor) - (Inssrance- ComDam-iPoum Numcrr) (—EaPirdon Date)
(Name of Coacrac'lo,-) Banc; Compan)-/Poucy Numb,-,) (Expui dos Daic)
(Name of Contractor) (Insurance Comcaay/PoLcy Number) (Ex�indoa Dale).
(a--h adu:oczl 6cc,if acccu--y to;nc!ud;informs :ioc pc r a to.11
I
{ ) I am a sole pr-op(ieto- and have no one working for me.
j I am..a home owner perforrni.ng all the Nvork myself.
NOTE:plesc be ca arc Lu .i ie 3cmcoavcn�.tio cz�lcy P=-om to L4,o—iCr^• -r�oa c rrar xori oa c d..�tL�of
j ant mat th_n[1=v t zia is%xtl h the Iwmoo<wc rtmde oc oa the g-ouM43 zppurt=-r_'tbcco c--c ox Cc=-1y ooea:d=cd to be
=Vlor=ucc?� the" =cc--ti--sicaAcz GL1S2-n1(5)).
t :.pp[intiw by a homooava fc c lieu;.or permit tray e.-;dcv«the
Icg.I nsvc of nn er�aloyx uodor ds L11kce,Compom,s�Ae[- '
—dcra,-ad tha a-SPY of this=-L--=¢uy ba f.-+.vrd.ad to tbo r}opartmcoa Acc4a2d ots—of tas�+rcooe for tb.
covernSe v='fic=lioa a.-td Uut raiha-e w")'crate trod,IDCGOa 25A of MGL 152 as icd to the=gosi6oa of aimiaal PerL W-
eom�smg of a floe orup to S 1,500.00 andlor of up to occ y=r_od coil peoattia in be form or.Stc9 Woec Ord-sad a
fl=of S 109.00 a day cptinsz tnc
For dGauta.ar.sl use only
f PcImrl NUML--r .
Lot
Signature of C=IScclPcrmiucc �� -- J
SECTION 8-CONSTRUCTION SERVICES J
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
<9�-Rea sWfe—&Home-fimarvverrieRtcdntracf'o
Egli
't Not Applicable ❑
Company Name Registration Num ee`
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.-c.152,§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...... ❑
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 Gerson 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.
JHomeowner Signature
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SECTION 5 DESCRIPTION OP PROPOSED WORK(check all applicable)
New House ❑ Addition ❑:. Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition New Signs [O] Decks [M Siding[O] Other[O]
ief Description of Proposed
Work: �� �ilf' % � � �•����L E" ����L f c�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
,..r".«c ..C^> a�y`
sa_t€New to se rich ocaddrEtio to eztstlfcthoustnct,�com tete°:th atiavr lna:
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 Ta-OWNER;A ATION-TO BE COMPLETED WHEN
CONTRACTOR' O UOWNERS AGENT OR A ILDING PERMIT
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
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.
Print Name
Date
Signature of Owner/Agent — C
^
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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
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
A. Has a Special Perm it/Vahunuo/Findi ng ever been issued for/on the site?
'
NO 0 DON7KNOW 0 YES 0 �
IF YES, date ionued:'
IF YES: Was the permit recorded at the Registry of Deeds?
NO v���
� DON-r m"w"" 0 .^"
IF YES: enter Book Page. and/or Document#
�� �� ��
B. Does the site contain ebrook, body of water orwetlands? NO v�� DONTKNOVV «~~� YES �_�
IF YES, has permit been nrneed to be obtained from the Conservation Commission?
-
Needs tobeobtalned x�� O6tm�me� �-\ Date |ssued.
�
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C. Do any signs exist on the prupert �� ��y? 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 0 NO 0
'
IF YES, describe size, type and location:
E. Will the construction activity disturb grading nr filling)over 1 acre orisd part ofo common plan
that will disturb over 1acre? YES r NO 0
IF YES,then o Northampton Sunnn Water Management Permit from the DPW is required.
W
iGity of Northampton
Department
$uilding rr
a
212 Main Street ` aE �� ..•
�y Room 100 ...................l
Northampton; MA 01060 Mr��tans��� �
phone 413-587-11240 Fax 413-587-1272 P[ot� fatl� � �
• , +� 'Other, e y,�'a �` - � �� �+o! � �'+
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITEJNFORMATION
1.1"Property Address: section. be coropfeted bofi�ce
' ' Nlap ;y Lot Ua�t•
El rnBt District ' CB DisIt dt
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
N - /
4 G C- Telephone
2.2 Authoriz, 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 0
This SectiondFor Official Use Only
'Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2005-1101
APPLICANT/CONTACT PERSON HILL ARTHUR B JR&AGATHA N
ADDRESS/PHONE 25 BATES ST NORTHAMPTON
PROPERTY LOCATION 25 BATES ST
MAP 25A PARCEL 127 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: DEMO SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF ATION 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 ssion
2 200
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.
25 BATES ST BP-2005-1101
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-.Block:25A- 127 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildin4
Category: BUILDING PERMIT
Permit# BP-2005-1101
Project# IS-2005-1495
Est.Cost:
Fee: $15.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(s4.ft.): 11979.00 Owner: HILL ARTHUR B JR&AGATHA N
Zoning:URB Applicant: HILL ARTHUR B IR &AGATHA N
AT: 25 BATES ST
Applicant Address: Phone: Insurance:
25 BATES ST
NORTHAMPTONMA01060 ISSUED ON.5116105 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMO SHED
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 5/16/05 0:00:00 $15.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo