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DEPARTMENT OF BUILDrN INSPECTIONS I�
'212 Main Street • Municipal Building 5 •`'�
INSPECTOR North,•unpton,MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as 1:is/lier construction super-,- sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or w6 fame y
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 boil Ing department"for"the i ty of Northampton wants any persons)-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 DELAY the project until such time as the proper permits and inspections are
made
L 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
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(rri� I7{ �IQI,fI�i311l�IfDll _ � __
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w DEPA.RTA4E1,IT OP BUILD0,10 INSPPCTiolds
j 212 Alain Strcct ' Municipal Building
Northampton, Mass. 01060
_ -V-V0R1a-R'S COMTENSATIO.N L iSUR�CE ?.FFMA..Vj-J'
I
(li cctu^rJpermi flee)
a principal place of businessfresidence at: --
I -
_ (phone=')
do hereby cerrifj, under Cllc paint aDd penalties of per3ury, -hai
I - —
i ( ) I am an employer providing the following!v.orirer's cocnocas_:JO covc:'Sc for in)
etvplovees worlong on ties job:
(Losur�c Comm,) (Potic:NL-nirr) - (r,pinion DzL.)
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"') I am a sole proprietor, general contactor or homeowner(ei:c:e one) and have hired
the conuactors listed below wbo have the `ollo:vioQ worker's c000en–salon policies:
(N=c of Co —,O-) (InStrantr Colnoi-1y1Pcuc)- NUMLc:) �':73iJOQ (�11C}
(NzMC of Cont vaor) R srmzcz CompanyiPoUc; Nu.mcrr) (Ex3ir;,ion Dzie)
(Name of Coa=cro:) (Insurance Compan}-/pol)cy Numb J) (E.xpir bon Daic)
(Name of Coummor) (1aai c-- Compzay/Poticy Numb:r) (-Expir boa Dale).
(naai� d!i�oczl x�.ifnccc._g co c�c iaf«ZU�oo pcu iainfi io..11 o0c--=.0:a)
SGle pFOprietor and have no ooe worming for me.
( ) I am.a home owner performing all the work myself.
NOTE:pt=-,c be as uc t vj�le hemeo.�ac a wtio ecmpi°Y Persons to d�, C=—,=Qa c rcpa .r ark oa a of
no(ciort th--.n L"--tmta in%%xeh the bomoaw-oc read=oc oa the Qo,�z,,?urt.cas'3 the^ ,ox C r=Uy o_-d-ud to be
cixploycs unCc tt-� -=P---,:m Aa(G0 52-=1(5)�=APliotion by.bommav=fc:tic-«pcma=T c,;dm«cbc
Ic921 c,-.,,,of en apioyx undo d> Woe ,Coaspaoa.tioa Aa-
t e a+nd dl->Dopy or thi.mrzmem m,y bo focv..vct<1 to tb.D,,.„ arL.6.r,id A.e.r-e olsoa of l—r-tb.
eoveaa^c reiCetioa and t!t S f_iltac to uxiuc)Covc(ybt tmd,yz�ion 23 A or htoL 131 as led to the caaioa of eimios!pea.Wcz
Dorm i tg or.riot orup to s l500.00.ndlor orup to roc yr_r c.ad aNil pm.tia in=tic form or.Stop Work Ord=and a
rs=of s 100.00,d:y aCniast cD,--
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SECTION 8-CONSTRUCTION SERVICES J••
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
, _•. .. oT _ y Not Applicable ❑
9.:Re stered Hoirre'Tis� rorrei�nent~°C'antractcs - . ., h�.
Company Name Registration um er
Address Expiration Date
z /r S �£ !t ? . Telephone y�y
SECTION 10 WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M.O.L.c.1"52,§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...... ❑
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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 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
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check alt applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors 171
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[o] Other[p]
Brief Description of Proposed �-
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
saNev+ oiise �`iiTditiex>lsiicioisicr 61, aleth" o fiaiu:
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'AUTHORIZATiON-TO"BECOMPLETED WHEN
OWNERS AGEN*OR',CONTRACTOR APPLIES.FbR BUIEDING�PERMIT
I, A aA V (A// !>0 as Owner of the subject
property
hereby authorize A 40
to act on my behalf,in all matters relative to work authorized by this°building permit application.
Sign to ure of Owner 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
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Section 4. ZONING Al I Informatio'n 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
(volume-&Location)
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A. Has u| Perm�/Vahanco/Findi ever been bsuedfor/on the she?
/' 0 DO07 KNOW 0 YES 0 �
IF YES, date issued:':
IF YES: Was the permit recorded at the Registry of Deeds?
NO K > DON7KNOW 0 YES
IF YES: enter Book Pagei and/or Ducummnt#
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B. Does the site contain u brook, body of water orwat|un� �� VV �~�� NO v�� DON7KNO YES �~�
IF YES, has a permit been or need to be obtained from the Conservation Commission? '
'
Needs tmbmmbtoioed v�� Obta�oad /�� Dst�{ssmod.
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C. Do any signs exist onthe 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 x~� ND 0
IF YES, describe size, type and location:
E. Will the construction activity disturb grading,excavation,or filling)over 1 acre oris it part ora common plan
thowi||diomrbnvo,1ocre? YES K } NO K )
`—^ i ~^�
|F YES,then o Northampton Storm Water Management Permit from the DPW is required.
h. 7
City of Nort0arnpton :5tat�ts Pe
Building Department :
- .
212 Main Street e e eX" i
F vg
Room 100et uatst�lt � s � + 4
Northampton; MA 01060 o. 5trxr�ct ��rs.
phone 413-587-1240 Fax 413-587-1272 PtotPSttf'Cans �, � ��
Qtfier Pee fi x A., - .
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION:1.-SITE INFORMATION
9 This section to be completed`by offf''
.1 Property Address:
4.01;
Zone Overlay Dtstnct_'
EIm 5t District ;C13 131strict
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
A-1 1116
Name(Pri t) Current Mailing Address:
x �� -- Telephone
Signature r
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION'3-ESTIMATED CONSTRUCTION COSTS ,.�p : 06,116
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (by Estmated Total Cost.of
Construction:from 6
3. Plumbing Building Permit Fee
4. Mechanical(I VAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
ThisSection°For Official Use Only
' Date,
Building Permit Number. ` Issued:
Signature:
i
Building Commissioner/Inspector of Buildings Date
20 NORTHERN AVE BP-2006-0626
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.-Block:25C-025 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0626
Proiect# JS-2006-0920
Est. Cost: $2000.00
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 AMY
Zoning.URB Applicant: Edward T Corbett
AT. 20 NORTHERN AVE
Applicant Address: Phone: Insurance:
409 POCHASSIC RD (413) 582-3930 0
WESTFIELDMA01085 ISSUED ON.121712005 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 Signature:
FeeType: Date Paid: Amount:
Building 12/7/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo