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r� DEPARTMENT OF BUILDDZIG INSPECTIONS /
INSPECTOR '212 Main Street • Muuicipll$uildinD '>e
Norduunpton,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 sups::-:Nisor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a one or"t" ami 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 buil ing department for tie-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 Or 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 occupancv
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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DEPARTMENT OP DUILDF)�,,G JNgsp jot.'S
j 212 Main Strcct ' Municipal Dudding
I Narthampton, Mass. OIOGO
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_ «'oaxa,-IZ'S COINEPENSATTON G'fSURA�CE AFI? AA11-j'
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(1;ccnsxJpermiticc) .. --- --
%,.zth z principal place of businessfresidence zt: -- - -
-
J Co D��tcGk sr Lam, �I,9 ago (phone=')
(szr�t/cit-1a2jx1z:ip)
do hereby cerrify, under thc.p?int and penalties of perjury, h:i
{ ( ) I arty an employer providing the follo%vine'worke5 coinocns-n:ion coverage for 1111
etuplovecs worUng on tills job:
(Iasv_r-_n= CoarzM,) (Pekes;N r) — (T';pirr don Dz1~.)
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( ) I am a sole proprcror, general contractor or homeowner (ci cie one) 2nd h2ve hired
tine cone actors Gsed below who have the `olio,,wing worlke�s coLoen_�don pa>icies:
I
(N=c- Of Conlraaor) (In3tranc;c Cotnpany/1sGUc }-,tuII2L-Gr) (--.)I;-auon eats)
(!`lame of Coca-2cior) ( is-d ncc COMID Z`1poliC; Nu.Min-0 (ixpiraiion Daie)
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(N-me of Conmaao,,-) (Insurazc:. Comp2n)-1Pol;c}- t umbzr) ( xpimden Daic)
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(Nzmc of Contractor) (Inset-any CompznylPolicy Numb-r) (Espir6on Date).
CnIIOC3 ad irocal r'xG,;fn<cczz__y to mciuC�:inform.--ioc per f_,a to.0 wcs =O:. )
I
am.a sole prop 2nd have no one working for me.
( } I am.a home ovwer performing all the work myself.
i
NOTE:ptex be aware t,— }ije hems ve a'100 e=Ptay pe.-om w CSO=X;, •••• C=—. -ao a rcp2-u,Ork an L d.._0 of
trot most tin t:roe mrts is u'se's the bomoowoc raid.a oa the pout 6 zppurtc==tb=,o,:-c oot C=.r-.Iiy oo=.de-cd to be
eixploycs uaC..the w -,�_.,:�A={GLI52-=1(5)).--PpliC7(M by a bomeo-=f=--6c==n cc pe-mit n_-y e�idmcc the
1e w�l c=tu of as c=piayx uodar tho Woeieda Co�oo.AeL '
I uodesz�d tb+a x oopy of tbia mt—may be f—.—i-d to the p.cpartmeo¢of 1.• ^d Accde OM-or t�+r+ooe foe tbe
cOYe&oe ccirclioa aad duu Liitzt to secure toveryCn tnde=anion 23 A of MOL 132 an ied to the i�oxuioa of cimi¢al per3kic
evnzc:ag ora fine ortrp to SI X00.00 an&c)r stprisoorr oCup to coe yes a-,d c,il pma is tSe form of.S.op Work Orde and a
firs✓of S 100,00 a day LPI=me
-, For dc,.rta.�u,c only -
Pcrmit Numbs:
Sig= Lt �/Pctzn;tt�- Lace -- l
SECTION 8-CONSTRUCTION SERVICES •
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
g.Re ster/�ec;Eonreir (raveient;C/at�rtt�ra of . ''$ .�• Not Applicable ❑
9 t
Xe UCXy
Company Name Registration N--�um a� —-
A, a Cic- S/ �loid
Address Expiration Date
-- t-e—Ae6- a ice/
Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.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...... ❑
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 Win ws Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [[J] Decks [p Siding[0] Other[0]
Brief Description of Proposed *-- -- --
Work: _.[_uJ�1�'a(- V/X.Y C r eJ lV c f 5 U V 14LLjc - i �5
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa f€°�Nev+€_l�oase�and�oc�di�ii�,ta�existincoC's�rea�� pte��fhe�°�a•t(al>�i
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-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENTOR CONTRACTOR APPLIES=FOR BUILDING PERMIT
h 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/Al orized
gent reby declare that the statements and information on the foregoing application are true and accurate,to the best of m ledge
aeRIl5elief.
Signed under the pains and penalties of perjury.
{
Print Name 7
Signature of Own t D to
°
Section 4. ZONING All Informati6h 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
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
of Parking Spaces
(volume-&Location)
'
A. Hasa8 issued No' 0 DO07KNOVV 0 YES 0 �
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO K ) DON7KNOVV 0 YES
IF YES: enter Book
Page: and/or Dooument#
�� ��
B. Does the site contain a brook, body of water orwet|un� ��� NO v�� UON7KNDVV «�� YES �_/
IF YES, has permit been or need tu be obtained from the Conservation Commission?
'
Needs tobaobtained �~��~� Obtained �~v��� Date. �
C. Do any signs exist on the prnperty �� ��� 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 0 NO 0
'
IF YES, describe size, type and |ucatiun:
E Will the construction activity disturb grading,excavation,nr filling)over 1 acre orisd part oyo common plan
that will disturb over 1acre? YEGK ] NO K }
~~� � `�,
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
�����
City of Nortl;lampton �Fe
Building Departments
212 Main Street
Room 100erel uat Irf►f
Northampton; MA 01060 fu�vc�Sets3St
phone 413-587-1240 Fax 413-587-1272 ?PiSt
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by offv
1.1 Property Address:
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4x
7W .
-', ,Etmti CBIl�str�ct,
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED.AGENT,`
2.1 Owner of Record:
b A KJ I r✓L -e.. IL L 1-Y �� 5-/(��a r i Av A U e-
Name(Print) Current Mailing Address: 04
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
ature Telephone
SECTION 3-`ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (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
Date
Building Permit Number Issued:
Signature:
Building Commissioner/Inspector of Buildings - Date
25 NORTHERN AVE BP-2006-0769
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-034 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0769
Project# JS-2006-1179
Est.Cost: $1978.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq.ft.): 10018.80 Owner: KELLY DANIELLE
Zoning.URB Applicant: John Corbett
AT: 25 NORTHERN AVE
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:21212006 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• Date Paid: Amount:
Building 2/2/2006 0:00:00 $25.002367
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo