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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 Lis/her construction sup(:. ssor. 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
I, 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
4
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A -' f �laaartch atr(ta'
W DEPARTMENT OF BUIL.0f)'\10 INSPECTION'S
212 Alain Street Municipal Building
Northampton, Mass. 010G0
�N'OJUCER'S C06'CPENSATION -MSUR -NCE :'tl=I IVIT
(li aysxJpermJ afcc}
%VILh a pnncipaJ place of business/residence at:
do hereby cerdf,, under thc.pz_ins and penalties of perjury:, hal
( ) I am an employer providing die followine %vorkcr's comncnsabo covemgc for Inv
etuplovecs wor�ang on tills jobr
(LIMIran=Comrlm) (Pcbc-, Nu-a�r) -- (r , ration Dam.)
( ) I am a sole proprietor, general contractor or homeowner (circle one) ?Dd have hired
the consactors listed below crbo hive the folio%Vino worker's comnen_z on policies:
(1,�amc 0f Con=^c,or) (In umlicc COIn01n)-ii'obc; (i_>:DliJG f�atc)
- (Name of Conu-zmor) (insuuancr- Comoan,,v?o!ic; \unc^r) (%xvtr bon Datc)
(Name of Couaaelo-) (insurance Compan)"/Pou-q- Nambj) (Expim600 Date)
I
ON!amc of Conaactor) (Lasu=c-- Comcz.ay/Po6cy Number) (Expirttioa Daft) .
(ntsacb:Ai:.ocal cbcC.il acxury to c>Gtad=informa�oo peruiaias to.11 mom-x..0:3)
I am a sole proprietor and have no one working for me.
( ) I am a home owner perforrtitng all the work myself.
NOTE:ple be ewe d- .t Je bcc c=O crs wto cc ptcy pczoua to = cis c o c rrnr wor c oa.d%-U--y of
ant o th=L"rc-=ta is%%ych the bomoowaer raids oc oa the QouacS z.,-�purte tbeu a_-c 00c Lam•='qty oee�id.-md to be
cc*10ycs unde the +ui cf:0=:;> --,;ea Act(GL1 SZa I(5)�=p-pUci6m Iry>bomcoa-oa fw_6c=---.a pa-rah r>=y--,d—tL-
Icg,0s:=of=c=ployec under dse Worlcoet Coaxpom Oo AeL
[uodcaz d the>copy of thi-cz-L m m y bo fot- ,d.d to the Dcpnrtmccn of 1.6,,,;,J Accidrnti'offi—of Ir�—for the
cpvalsc v=jfJCstioa and a,--L L-ihac to ua=covcr tasdct soctioa 25A of MOL 152=lad to the imposi m of cim;n-U Pc v'L'o
ooasi.s�of a riac of UP to S 1}00.00 a,NOr bapriso�of up b occ yc�r cad c Vil P=,.tic w t•x form of.Stop W-+Ord`S`°d a
rrno 0(5100.00 1 d_y tptin4 me
only
Lot
,,.�rr;ry V PCTID1t t`I tSID�Cr
Sil nature of Lio=L5cc/Pcr niucc D-E—e "
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ? � ✓ �l u ��
License Number
Address Expiration Date
-71
Signature Signature Telephone
J ReQisteredorrie:Imnco�einentContractoi _ h Not Applicable ❑
Company Name Registration Number
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...... ❑
UAW
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 and State of Massachusetts General Laws Annotated.
Homeowner Signature
+ s
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [E] Siding[0] Other[0)
Brief Descriptio (�
Work: ,of Proposed F✓�i 9:2 ✓�° ., lryuct 1��+C,!' 3C� <.G�csr
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa lfMW hoi:IS4;g add trofiddo exls 66M acomp et fWi 611ov �ng:
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= OWNERAIhTFAON,- O OPLETED WHEN-
ILDEMOWNERS.AGENTJR CONTRAGTORAPPLIESN FOR..BUG RT
as Owner of the subject
property
hereby authorize i( � 1 d 15
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, C IV It.112 4,-J,yt tiid- 'c, 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
Signature of Owner/Agent Date
^ p
` -
'
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
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
Fill: 4
(volume&Location)
A. Has a Special Perm it/Vurance/Fndi ng ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded et the Registry nfDeeds?
NO ��� � DON7KN0W 0 YES
IF YES: ' enter Book Pog and/or Dooument#
B. Does the site contain abrook, body of water urwetlands? NO \_� DON7KNOVV x_� YES
IF YES, has permit been or need tube obtained from the Conservation Commission?
Needs tobeobtainmd /~-� Obtainmd �~\ Omte |ssumd�.
\~� �_� '
C. Do any signs exist on the propert �� ��y? YES �,� 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(clearing, gradingexcavation,nr filling)over 1 acre nrinit part ofa common plan
that will disturb over 1acre? YES NO � )
/F YES,then a Northampton Storm Water Management Permit from the DPW iarequired.
P !l
�ti�Clro�M4rthampton sta `: rantL �" x
\, Iding apartment
r 2�2 M*6.Street
ZOO Room 100t�e xaati �=T
ortham�ptan, M 01060
phone 413-5�710 F413-587-1272Ii , "
APPLICATION Td CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: x
fihas.sectJio'n fo tie completed byoffice
C r
UnIt+..
Z:oAe Ouerlay D�sfncf. � -
-� � disfcrct' _ _ C�Disfr�ct
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
S�-
Name(Print) Current M i'ng Add s
_ Telephone
Signature
2.2 Authorized Agent:
�.. .:�„��.,� i�•�.t k.dl.�S �-�- `ms`s`,.� S�.
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 f3, (a)!-Building;Permit Fee
2. Electrical -(b)Estimated Total:Cost of
Constructionsfrom-6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section-For:Official Use Only
Building Permit Number. te.
r.
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
i
I
�~ R' BP-2009-0063
GIS#; COMMONWEALTH OF MASSACHUSETTS
aj"i�. ', . 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-2009-0063
Project# JS-2009-000079
Est.Cost: $8000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: C PHILIP ANDRIKIDIS 150673
Lot Size(sq. ft.): 27965.52 Owner: SPEYER SVETLANA
Zoning.URB Applicant: C PHILIP ANDRIKIDIS
AT. 124 NORTH ST
Applicant Address: Phone: Insurance:
52 MAIN ST (413) 585-9171
FLORENCEMA01062 ISSUED ON.711612008 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP, PLY & SHINGLE 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 Signature:
FeeType: Date Paid: Amount:
Building 7/16/2008 0:00:00 $25.001763
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo