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of Nart4ainptan L Z
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d DEPARTMENT OF BUILDING INSPECTIONS /
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INSPECTOR 212 Main Street • Municipal Building '
Northampton, 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 iris/her construction supc.-:*1 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, 'X understand the above.
(Home owner/resident's sighature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.e.
�
Date '1
Address of work
location
$ d }ilxsantfl its rtls
m DEPfu2TMEN7 Of' LLTILDD7 G INSPECT'ION'S
212 Maier Strcet ' Municipal Builcling j-
Northam-pton, Mass. 01060
WORICER'S COiY1TENISATION INSURANCE A < IDA NIT
1,
�:ith a princip'd place of bus, esshe:,idcncc t:
--.---- _
do hereby certiiti. t:n;fer the rt�a rls ;°.nc pelf,iiic:; pr.sjusy, that
I am an employer providin- the compcnsavon cove:avc '107 ,11Y
employees worltdng on this job:
(InrrranG Co>� m') ( c c:Nt�itxr) --- ("r3.�.ir ion Date)
( ) I any a sole proprietor, ventral c-n=ctOr or horn(oO oer ;csLrcle Oct) and t;a,:e iured
thiic- contractors hsted beiovv";,'�:.0 il�. lht f) o � j orn pIs coL e n
(IIame
es:
of Contnctor)
(Name of Con(r:c<,07) -- ZlzsJ:o nee Con?Da viPedie!' Numb--r) (}: r,:tiny Date)
(Namc of Contractor) (173adr3SlCti Co n,an�;i�o1;c; T tul�tr�rj- -s.ir.:doa mate)
- (Name of Cont—actor) _ (Iru1 rand Come ,y n o1i v Numly_*) Dace)
( � I iLIl t, sole 1?I"Gl?I�le:t?i� i'.T1II i1H'JC', i10 OI:C "�.'i;?I:.iiih tOr i11e.
NUTT:plcsc LC awzr c 011'.v ilc ., ,o r-pi..ry;rz :n::>;_�__rs�t�cz::: n r�C.
not UKICC than tlnbo units in%�4,_d+: he 1;:-,.:.Zr r z:c:=Cr oc; gni_:r_s zr•r crsnI Lhac c e c rx{ rrzlly v:r: h
cmptoyc3 un.�-et x:(G;.152-:z 1(5)),at:, .a;ir_;by s hotaro:-�`:cr e G—zI ct P7
legal rtalw of an employer under tL•o WcNtkcli CO,=)Or XiOn!.cL
I undo.-ztand thsi a cony of tti�ciatci s:r:ay bo jcx,,v,vcioJ tot;e IYlxirt-x,cr,:of IndiutriJ- C:uoo of!:1�-4 for UM
covcrxgc vmrc-lion and that filtuc to ut;3:-'C i- 25A of MOL.152 can lend to tlx im ziiia�c;cr i.^1 pcc sL:s
OOQIisdna of a rtZY_of Up to S 1,500.00 n:T.a.'(Y 1�:;ir:Yy,-T_:il of::p to cr.-}:Vr e:-.I Civil perultia in dK(—n o(n S!r, ri.<}t:�tn'j a
fr>r oCS100.00 c day tgs.iw't m:.
ror d'-p.11>'stil 11—cxrty i
Pcrrnit NlluA>L:r _—._.---------___---
Si-nature of! jc� tr,;
SECTION8 G0 UCTION SERVICES
8.1 Licensed Construction Supervisor: N t Applicable ❑
® ( S
Name of License Holder
1 License Number
Q - C) S
Address Expiration Date
fit' 13 S � a 3°t I
Signature Telephone
e e e t Aar ,m u� en. -on racto; No Applicable(❑`
Company Name Registration Number
Address Expiration Date
Telephone 63c
SECION30 WORKERS' COMPENSATION 1NStJRANCE:AFFIDAVIT(Mr;G:L.,c. 152, § 25C(6))
.. �w
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...... ❑
gig!i
s_. .� :,__ _ • Ili
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
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SfCTiON -ESR P-Tc�ONLFPROPOSEDWORK cMec at a hcable
i
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing .
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: 4 r 4
Alteration of existing bedroom Yes No Adding ew bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0- Sheet 0
.r addition fOURi-fl- ouSrngg comp e=,MY, (:TV119
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
L 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 .
1. Septic Tank City Sewer Private well City water Supply
SECTS®TILT 1fIlRERA�TRORIZATION TO BE COMPLETED WHEN
OWNERSA ENS •0 O�IVTRAC70R APPLIES FOR BUtLDtN`G PERII!I1T
I, �Y'bQr Yob o\ as Owner of the subject property
F
hereby authorize �(�— ��a to ac; on
my beh f, in all matter tive to work authorized by this building permit application.
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Signature of Owner Date
11 'CrC�� �� �j �� 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.
lob -O� Q
Print ame
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?
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:
________ _• y of Northampton
wilding Department
I� X12 Main Street
Room 100
i U N 2 8 2004 I e 'ampton, MA 01060
phone 441p 3.5 7.1240 Fax 413-587.1272 ,
-- ref PI 11 n�' �tihl -3J
a
-XMTC`�TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
r
1.1 Property Address: �z
MaJ W
V-� P Ld. niter
EIm�StDistrict .; � �- .� �� S;D�rstrct �-
SECTION 2 PROP ERTY,OWNERSH,IP/AUTHORIZED`AGENT
2.1 Owner of Record:
�3 (�,�, 1�. oA Ye,
Name(P -nt) Curren Mailing Ad e s:
r %Jw Telephone -
Signat re
2.2 Authorized Agent:
��'�
jNa. Print Current Mailing Address:
�.� s 03c)s ,
Signature Telephone
SECT10N;3.- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Us.e"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
Building Permit'-Nu b Date Issued:
L$Jtnatu re:
Building Commissioner/Inspector of Buildings Date
T
s
43 LINCOLN AVE BP-2004-1329
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-055 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-2004-1329
Project# IS-2004-1996
Est. Cost: $3600.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Robert Thibodo 118441
Lot Size(sq. ft.): 16509.24 Owner: MORGAN BARBARA&JANE AULISIO
zoning:URB Applicant: Robert Thibodo
AT. 43 LINCOLN AVE
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586-0391
NORTHAMPTON MAO 1061 ISSUED ON.6128104 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 Sienature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 6/28/04 0:00:00 2102 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo