25C-057 (3) •tHAMP�. � .,
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Grify of Nart4amptan
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6 DEPARTMENT OF BUILDITG INSPECTIONS /c
INSPECTOR 212 Main Street • Municipal Building '
Northampton,MA 01060
,r
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-,,i 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 buildine inspection (before work is
concealed), insulation inspection (if required) and a final buildine 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
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 L Z
Address of work
location
a (Ij of ,artliallip till
� 6 fi?c�eacllnsrlle
m DEPIJRTMENT OF BUILDING INSPEC'T'IONS
212 Main Street ' Municipal Buildirig
2\,Torthampton, Mass. 01060
NVORICER'S CONITENSATION INSURANCE ASFU)AVl-T
i,
\:pith a principal place of bus_nessJre: eenc
-- - ----- --------- ---- - ------- -- -- —--T h(;ul C
(strc.U'cit:i:,..._:rr'p) -- --------
d0 llcrel)}' CCI—LIY- llil:'cl" tI1C p 111E ,1i1ti [)Cil iilC. Oi 1^Cr�ll[�, t.11<'+::
( ) I arri an employe;- providing the iollo`,v;[lt ••:orf_c1`s compensation coverage or Iny
elnplovees worfdrlg on this job:
(Lus-=Ca j Company) c;Number) ---- (ExTi>vlion Date)
i and a sole proprietor, zten._FL Conmc`or bomcovrcer (CLcle one) and Have autd,
the contractors listed beiov,,.vl;o ll� „ the `oiIr :L; :,o-�ers cor!loensa�or.,
(Name Of ConLmctor) (Rc 11C LCI^^"::i"i l Gll-{ Nuinbc-r)
(Name of Contr�.ctor) -- (71ISJr,_ncc Co na.:`vPe!ier �umrrr) (E r tine Date)
(N'amc of Coat actor) (Inst s.cti Co -: ,rPel;c: Nusi lxr) ~.z.:r dor. Datcv..
(Name of Contractor) (Insu>-ane:. Co1nr,:_ti;rt'olicr Numb-r) (I:;. -t:iG- Date)
C 1 ilia 2t ,;ole 1)r01)iIl C�)i 1'.11:1 hI?'r'C n0 On U���1ii tor ill C.
�•j� di l 2 ho[1IC OtiV?1Cr i)Ci:i)`illli'`-'
NO I fi:plcu Lc a>a c Cfst'.L-:jc I <r<o.11r cr::,?au. ^:i:vn:&,, 11ir.:,;..
rot¢rcYe than Liu-cc t:ri+s in tti:;e+t;he f;: .i zce:<: a-a;'`>.- � ur:ce_:r+Lhcdc e:t ext�c.-tcrzll.;c<K::::�::c:::c h:
c 1ployc3 urv�sr tlr�w:i:: s ccT•_: i a tr ((-r:.1 S2 s!{Sl;.z . ._:.:ic::by hoca o«to`or a Gccu c�per;:c:: me
Icgzi ctatuc of an a¢cplo)'x under d1c WcVkc1[Coa;rar.ti n z4xt-
I undo ilaad dixt a co?y of ltu elate:x r.y Ea faw,uciol to t_'»[Y.txi of Iivf is ricl of!: ua rn for tIx
oovcr&< c vaifictioa and that fa urvm-to a_a-c co'._ - t:r.,�._�uc(ir,:2;q af'.tG1,1S2 can Ir ci to tfx i.�t sition of r.:=_.1 pct:al::ca
coca sting of a fur of up to S 1 SOU.�J a 'cr i :}triux� :!of::�to cn } r.=.j civil[r1v1�_in do I nn cf a S!r,,`;vc i_ ! trd
f rw oC S 1 0.0.00 i day�r:_in:t rr
For dq i slrltsl u.c curtly i
. Pcnnit Numlx:r __—_
^ Sirnntut tlf•I,ic Ir C! I'crn „ter
A
SECUON,8. CONSTRUCTION SERVICES
-
_. r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Re s e,e - orn. .m vemen: C ntracto - Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION` b„WORKERS' COMPENSATION INSURANCE,.AFFID.AYIT(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...... ❑
n
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 ?iGa ��
SECTION5. DES -f2IPT O1JOFPROPOSED WORK(check X11 aoalicale)
':;; rxax�*� .Pi's?-'� ,"'x..� ,.»x .,..,. •�',�'�' ., 3n.r �
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ja Demolitio11 New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: &1f _u�: _ /� a�u 2520
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet 0
6-5M ::.e MOM d o �ddi'ti0ntto,eirMiff- housing�comple a lie f6[13 w 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. 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
ECTIOh[ a OWNERAUTHORIZATION =-TO BEiCOMPLETED WHEN
OWNERSAGEIF�OR'CONTRACTOR APPLIES FOR BUILDING PERMIT=
(--1 �� 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.
Signa re 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
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
X
Frontage
Setbacks Front
Side L R: L: ,/ R: (V
Rear
Building Height
Bldg. Square Footage , %
i
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?
NO X DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW 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 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
V
Q ing Department
c ;WxA
Main Street
X11` oom 100
� �4 Nor ham ton MA 01060
'phone 87-1 40 Fax 413-587-1272
�Is
APPL1�iQN'T3STRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
"ihfs section to be completed by office
1.1 Proaerty Address:
SC4C} 4 i. k M t' n( Ff fF
x s
1�,�, done" Overlay D�sttict
art Al i'Y)
:?gE#tn a7CrxD�stnct _ ;`G$DIStC1Ct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
N ,tom, c C A or
Name Current Mailing ddress.
C LL.. ' ✓ Telephone
Sign re
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. Building �Q =(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'ForOfficial Use Only
Building Permit Number: <<0 Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
31 LINCOLN AVE BP-2005-0110
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-Block:25e-057 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Build ft DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:she BUILDING PERMIT
Permit# BP-2005-0110
Project# JS-2001-1676
Est.Cost: $3500.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grote: Homeowner as Contractor
Lot Size(sa. ft.): 27007.20 Owner: LAROUCHE JOSEPH E&ROSEMARIE
Zoning_URB Applicant: LAROUCHE JOSEPH E & ROSEMARIE
AT: 31 LINCOLN AVE
Applicant Address: Phone: Insurance:
31 LINCOLN AVE
NORTHAMPTONMA01060 ISSUED ON.7130104 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL SHED TO REPLACE EXISTING
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 7/30/04 0:00:00 3299 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo