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�" DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR
212 Main Street ! Municipal Building
Northampton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction sul, , sor. '1 he sta.c defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two family
divelling, 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 rouzh 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 r 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 5-1.1 Q1
Address of work
location
0/D
11LA,-fPTO
0* Ilk (r2 �1 x1 171 (?billl�lti111
8 6 f3lasaachctcctla' —
m DEPARTMENT OP LIUILDrNG INSPECTIONS
212 Alain Street ' Municipal Buil(6ng
Northampton, Mars. 01060
WORKER'S COMPENSATION INSURANCE A FIEDAM
(liccnscrJ�.rrnituc} � - —
,,vith a principal place of business/residence at:_3 y Rve,
- -- (strLe-t/c�ty/statc��ip)
do hereby certify, unf+er the pa ins and penalties of perjury, Ohat.
O I am an employer providing the followirnc; .vorkcr`s compensation covera;;e for In
employees Working Oil tliis job:
(Insu=c-z Comp?my) (Pelie;Number) ---- (ExpimL on Date)
O I am a sole proprietor, general contTactor or homeowner (circle one) and (lave fared
the contractors listed below who Have the foll0VVm' g workers compensation polices:
(Name of Contractor) (Insurance CompanyNoticy Number) (Expiry ion Date)
(Name of Contractor) --� (Jnsurance Comoaay/Poticy Nmb--r) (}:zpiraioo Date)
(Name of Contractor) (Insurance Compan}[Policy Numix.r) � .x, .a Late)
(Name of Contractor) (Intranet, Comc<r,ayRolicy Numbir) Date)
(a[tac3t tdiitimal c?kct ifr.cr<:ir:-::^ ��,�].:::c i:_:.smc:ia:patainu:,•.:all cr<:-sdt::-.)
i
O I <un a sole proprietor aT1d have no one .,�orking for ale.
I am a home ovine: perionnin- all the woi'.: r„yself.
NOTE:pIczse be aw-ue tlta:�s':ilc JK( nco��1Y_r3 ti e-,Play 0 s ;s to<.)cainlcnance,axr:n:c-"Y cr 1-,P it
not tncYt th n thruo units in u{idt tx ouirr rn:�s or at t`>c u rAS zpFurtcc nl thereto uc k4�crrsallV cr :c ::' tti
cmployaa u_ndtt th,worlte--at-; --tics Act(G1L152,"I(5)). a hotnco%NT r fort I ccu cc pern:i:r: r.: >c t:'v
legal etahcc of an aMployx under tL•o -
W"k c Ccun;mnation Ad.
I understand drat i copy of ous ctatca ai¢ y bo forw• do d to tlw Dq tzrnf of li>d rs rial Alcid+&Ofrio of liar x for tln
coverlge vaif cation and that C it rrc to:ca rc covcrxbro ttr.d r zcctien 25A of t f4I,]52 can lead to the inr ifion of ma�1 per alt:u
ooasuting of a fine of uP to S 1 500.00 and cx of up to orx-yrzr and civil Pcrraltica in tfx foon oft,Strr WorF()-&a:d a
find a(5100.00 a dsy s£aini ttr-
Fcr dc{utnrl Csl U-only
PCtlnit Ntlrntxr
t, Si atureofl_icci, JPc rill tttcc
SECTi0N8Cb;NS�'TRUCfiI,tJN SERVICES
8 1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
r9-- Reg eretl I�"m�e 'mprbvement Contracto'R=11 Not Applicable El Company Name Registration Number
Address Expiration Date
Telephone_
........ ..... .. . ....
SECTION 10 WORKERS' COMPENSATI6N'IN.51UPANCE AM DAVIT(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 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 rd State of Massachusetts General Laws Annotated.
Homeowner Signature
SEtnTIQN D �S. R PT O 0 MAROP..OSEb' ONO` all�a licabl al
3Wf AMY �., .RYM4 * xSar.� +A
�.� .. mps°sifitY�. `"'*,
. : ,"3xb". i ?*s 'np Kµ' .': .. s,"..v '{ ?
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: ze'-wouc' c rot pt,/a y nook) ",f�4K4
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑• Sheet❑
6 Ifi New o s"e d'o tldi`t`ion to existing houSinf7 com"�p e`te the fo11bow—i�n�:
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. 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
SECTION 7a �OWNERAUTHORIZATION -TO BE COMPLETED WHEN
OWNtkgS AGENT O�R�CONTRACTOR'APPLIES,FOR BUILDING 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
Signa re wner gent Dat
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 ont
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
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 _� DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO 1/ DON'T KNOW
YES
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:
City of Northampton
Building Departments e
212 Main Streete Se
Room 100
Northampton, MA 01060 . a
phone 413.587.1240 Fax 413-587-1272 Plotl Ite an
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 completed by office,
3,7 ,ids'4 Map Lot llNt
Zone, Overlay;Dtstncf
Elm St.District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.11 Owner of Record:
Narne(Print) Current Mailing dress!
Signature
--- — "elephone ----
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 i
completed b erm(Lapplicant
1. Building i (a) Building Permit Fee
2 Ele,trical (b) : stimated Total Cost of
Construction from 6 _
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
i5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued: _
Signature: — ------------ - --
Buildmg,Commissioner/Inspector of Buildings Date
BP-2003-1090
GIs#: COMMONWEALTH OF MASSACHUSETTS
." CITY OF NORTHAMPTON
Lot -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-1090
Project# ]S-2003-1729
Est. Cost: $300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa.ft.): 23565.96 Owner: SMITH RICHARD F&ANNE D
Zoning:URB Applicant. SMITH RICHARD F & ANNE D
AT. 39 DAY AVE
Applicant Address: Phone: Insurance:
39 DAY AVE
NORTHAMPTON MAO 1060 ISSUED ON:5129103 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE GARAGE ROOF
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 Sienature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 5/29/03 0:00:00 1248 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo