25C-024 (8) ¢Kt1AMp�,
(rite of Warf4a ytan
L r
� � �4iTassxclfiisetts -
r
is. DEPARTMENT OF BUILDI]�G INSPECTIONS f=
INSPECTOR 212 Main Street • Municipal Building '%,y
Northampton,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 supc:-:'sor. 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
v 4E (S-zip; Of ttz tlj�il�t}�tnit _ .
� � d filasexcflusrtl� '
^z D"J'ARTl.fENT OF BUILDNG INSPECTIONS
212 Main Strcet ' Municipal -Building j
Northampton, Ifass. OIOGO
WORICER'S COIN'T ENSATIOIN INSURANCE AMA IT
�:ith a principal place. of buslrless/residerlce. ..
MTh( n` ''-------
do hereby certifti- t]IICer the p ins ,:ild pcil itiCS o -pp Ilry, :ha,.
O I a-m an enmployer providing the followulc , ort_cr-'s compensation �;overa�c 1*01 my
elzlployees working tan t?1is job'. v
(In--=cG Compamr) o! c;Namber) (�t� iT i7^n Date)
j I mi a sole proprietor, :=eneral conk or hon,:emvou (Ci c1e one) and t":av 'Hired
t.h contractofs listed beiov+ '.; 0 it th1� `.Ci1 .; -,•�oFkPrS COin�°IIS Ori 0li '. 5-
,,Namc of(wiLmctor) (Lnsu-:ric Ccmr-.:i;;Pcl.ic{ Nusnbcr) ;r>; . .ac-Dzic)-
(Name of Couti c,o-) (,i ZSJr,_rcc Con _ ti'(Po!ic Ntr7�r) (1 7:o:raiioa Date)
(N'ame of Contractor) (Ias"Immc-- Cot ;;al3.;i?okc-; Nujnh,,r) _~x,=rdo❑ Dar,)
- (Name of Contactor) Dare)r _} l
( J i1IT1 ]. soli pl UprlCtJi a"11 hav-,- no OI'. UI" ii` f0i ;11,'.
11ii1 a hollic Owlle` iiCr:C�1?11Ii� 111 iL ... iii',` lf-
NUI F:please.1r nt,W c c:nplI ;r:. ., :n
not mete th--a thr=uniu in u a;'` _:.^s x N•ttcr l LhcCO 2 n t I crsallY ccr.: h
cmzploycs un.,-r t}r wc:�: _ar x-� cn tr ((�LIS�, l(51!,a:i:_ :ic:;by a hotnoo,t-r_r`cr a l ccu a F=rz:!::: r c
icgal rtatuc of r.3 an?ployx undo t:n Wcv�c c o wriiion .ct
I understand that a copy of elan ctatci.xt evy bo faw�vc:v-.i to t!n IYtintt.xra:of Induzricl�z1�r:f Chico of[:::+.vcn-o for t!x ,
covcage vcif ction and Lhat f..iltrrt to tc.....e m��r_,,,ur,�::c�.irt 25.4 ct?.tGL.IS2 ran lead to the imposition��Ir' i_.l pa'•'I':cs
com sting of a frry_of up of::p to cr.-} e:.j evil Ferulties in
Lr> of S100A0 a day izr-ir1:t m:.
For&, •, trzxslsl tt ac c�tt}'
Ycrrnit T1umtr r �. --
5!�naturc of ,.iccn�;cJl omit±r-., ,
SECTi0NiZ CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
g tr ^'^ Not Applicable ❑
��Re sere -om mar"overnent� .� , ., -
Company Name Registration Number
Address Expiration Date
Telephone
SECTION i0 WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.-. 152, § 2513(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 fer 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
MI
16B S, •RTTaONOFPROPOSEDIYORK oheckfl a I�calihe
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing .
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks
[ ) Siding[ Other [ ]
Brief Description of Proposed Work: 6 , j1 t'112
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll D • Sheet D
+a ever ou rt ; c3d:i i.orJI existing:h uo sin Vp1' tff-er, lowrnzr
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
S,ECTO ll(►I RUTFIORIZATION TO BE COMPLETED WHEN
O�N��,��,�E� O�CONTRACTOR°°APPLIES FORBUILDING PERMIT
I' as Owner of the subject property
hereby authorize to act on
my behalf, 'n all matters relay ive to work authorized by this building permit application.
Signature of Ownery Date
I' 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
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 Front
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?
r _
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 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:
of Northampton
'n �Ilding Department
,212 Main Street
Room 100
N'd'.rthampton, MA 01060
phone 413.5$7-1240 Fax 413-587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
'� ,�=This settro �'to�6 com Fetedby�officer�'����
1.1 Property Address: k
I /Gp�/ Map ��� Lo- it
Elm$tDistrict ,T� GCB Dis rtct
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Byi t) / Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature T 1 phone _
S"ECTION `- ESTIMATED CONSTRUCTION COSTS
C..
Item Estimated Cost(Dollars) to be Official!Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) _:stimated 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: Date l"ssued:
L $ignafure:
Date
Building Commissioner/inspector of Buildings
T
18 NOR t AYE .a BP-2004-0364
GIS#: COMMONWEALTH OF MASSACHUSETTS
m4y: 0c CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category_ BUILDING PERMIT
Permit# BP-2004-0364
Project# JS-2004-0524
Est.Cost: $7000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Edward T Corbett 119488
Lot Size(sq. ft.): 5009.40 Owner: WILSON KEITH P&AMY L
Zoning: URB Applicant: Edward T Corbett
AT. 18 NORTHERN AVE
Applicant Address: Phone: Insurance:
1 TERRACE VIEW (413) 584-2546
EASTHAMPTONMA01027 ISSUED ON.1011103 0.00.00
TO PERFORM THE FOLLOWING WORK.STRIP & 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: Receipt No: Date Paid: Check No: Amount:
Building 10/1/03 0:00:00 MO $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo