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DEPARTMENT OF BUILDrXG INSPECTIONS
INSPECTOR '212 Main Street • Municifal 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 his/her construction sup(;:,:Sisor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,a one or two
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 r',egulations. 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 ULAY the Twoi t until such time as the proper permits and inspections are
made
�A understand the above.
(Home owner/reside is 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
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DEPARTMENT OF BUILDING INSPECTIof.'s ;
-
212 Alain Strcet Nfunicipal Building
Northampton, Mass. 01060
_ «.'ORt —RIS COi\2PENS�.TZON GgSUSANCE A17FMA.Arl,
I
�115xlpcnni tcc)
with a principaJ place of businessfresidence, at: — -- ---
i
(phone`)
— (svtiwtici ty/s a t r ra p)
do hereby certify, under tllc.ppinS 2nd penalties of perjuf , thai
( ) I ern an employer providing the following lworkcr's comocnsado, coverage Cor 1111
etn4�ioyces wor',3ng on this job:
(Incur-� Conpr*,) (Potic:Nu_- cr) -- (T:-pimlior, Dal^.)
I
( ) I am a sole proprietor, general cootraaor or homeowner (ci;cie one) and have hired
the contractors listed below who have the foUowing worke>'s coi oen_',-_tion policies:
(-1.13 llC of Cony actor) (Insuranc Corn03 1)•pi GUc{ N1U.MLCr) (-J:7 ,110
(Na me of Coac clor) (lns=cc Comoam./Policy Nt_lcrr) expiration Date)
(Name of Contractor) omsuraoc; Compan)•/Poticy Numbe.t) Date)
I -
i, .
(Namc of Contractor) (Insurance Comcwy/Poticy Nttmbcr) (Expiration Datc).
(aa�Gll �•oc7J r'xa,il acc.�.c 1•w mcud_iafw=t nca pct.aaains to an
O I am'a sole proprietor and have no one worhdng for me.
jI ) I am.a home owner performing all the Nvork myself.
I NOTE.pleat be ca yro(fi•.K1 JC bemeov vmµ'bo cr4play pczom to do �c r rruu Work ou l dc -;:of
iaot meet th ttsw�J is uS6 the bocaoowoct rc}ida or oa the Uouncb appurt.ca:r1 ibcGO c-r ooc C-.12y tees d-ni to Lc
eitplaycs 11 e the-- :xop•-+;m Act(GI_ll 5Z=1(5)�appli=Lioa by a bamcoQaa fm--6c=_-cc per it rr_y cv+d_n=tLe
Iegl cr=ass of nn exployx under dto W oh ora Compom.tion Ad
I uadcnaad tha>oopy of tht,mt®mx m.y ba f.--,id tv the pcpnrtmm2 of A c dray C ffM-or L>rur.000 for tie
eovatse reiCaiioa and Ihs L-iliac to s«urc)covc�U06C soezioa 23A of),((3L 152 c3a lead to the impositiw o(eimiaal peazlIio
coosisag of a fiat orup to S1 500.00 and/or
I=of 5100.00 a d_y tptima me � �oCup b ooc yor rod a�i7 paialUC m`x form o(a Stop Worti ordl tad a
only
Permit Numtxr —
� 1.dap" Lot n
� Si ofLi�/Pctmittcc �—� -- �
SECTION 8 CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
7 C.:uw+-. e. :-= nawm-3 c,aa. m°^� acs ,�.�
9J2eatstere home:mprovemerrfdCon aU Not Applicable ❑
Company Name Registration um er -
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL.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-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 rime,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 Zo 'n Laws and State of Massachusetts General Laws Annotated.
/Homeowner Signature
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SECTION 5-DESCRIPTION OF:PROPOSED WORK(check all applicable)
New House ❑ Addition [] Replacement W' dows Alterations) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [M Siding[0] Other[C7]
leef Descr' on of Proposed
Work: Q c'6_
Alteration of existing bedroom Yes No Adding new bedroom Yes No -
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa 1f�+fevir#loase.andor��d��on�t�ez�sfin�hoastncr:Y.camntete:thei'fOtlorvinp:
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. Wilt building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION Ta-OWNER AUTHORIZATION-`TO BE'COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT
I, 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 + t �4
Signature of Owner/Agent Date
Section 4. ZOITNG 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
11 [ t i
Frontage
Setbacks Front
Side L:= R:= L:s R:!
Rear
Building Height
Bldg.Square Footage ( % —�
Open Space Footage I __ %
(Lot area minus bldg&paved i
parking)
#of Parking Spaces
Fill: `.
volume,&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:` i
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 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
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 I NO 0
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(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES , NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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.�f Nortoarimpton
ding Department
,�2, Main Street
s ; i doom 100 f �
e .
No faa' ton; MA 01060
CC i 2pQlohe-413- 7-1240 Fax 413-587-1272
At!!I5A'fIgN 1't�,PQN r ! C LTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 =SITE INFORMATION
1.1 Property Address: F This secfion�a be corn feted bxaffice
. TE S' s Map < rtLot. 3 � unit
' /
/AO i ti/AIn P%U M,4 =Zane y
Overla D�str�ct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Al)* S7--
Name(Print)/ Current Mailing Ad re
11-1 X Telephone
Signature
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 uilding .� (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
Building Permit Number. Issued:
f
Signature:
i
Buil�'ng/ ommissioner/InspectorofiBuildings Date
a •
26 BATES ST BP-2005-0492
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25A- 141 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0492
Project# JS-2005-0643
Est.Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 29620.80 Owner: ALLEN JOHN&BEVERLY KENDALL
Zoning.URB Applicant: ALLEN JOHN & BEVERLY KENDALL
AT. 26 BATES ST
Applicant Address: Phone: Insurance:
26 BATES ST O 218-4144 0
NORTHAMPTON MAO 1060 ISSUED ON:10120104 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 10/20/04 0:00:00 7304 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
26 BATES ST BP-2005-0492
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-Block:25A- 141 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categ_oa: BUILDING PERMIT
Permit# BP-2005-0492
Project# JS-2005-0643
Est. Cost:$2500.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor. License:
Use Group: Homeowner as Contractor
Lot Size(s4.fu: 29620.$0 Owner. ALLEN JOHN&BEVERLY KENDALL
zoz:i : LTiw thMvliegrt AI_LEN_JQHN& BEVERLY KENDALL
AT: 26 BATES ST
Applicant Address: Phone: Insurance:
26 BATES ST 218-4144_Q
NORTHAMPTONMA01060 ISSUED ON.10120104 0.00.00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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:O Ar
THIS PERMIT MAY BE REVOKED BY THE CI Y OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu an signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 10/20/04 0:00:00 7304 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo