25C-076 OQ"�t1A1yP�O
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�., DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municip,al 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 his/her construction sups:,,isor. 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
�ttAN1>IO ?
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DEJVJu TMENT OF EUILDI? G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S CONITENISATION1 INSURANCE A. i t AVI.T
1 / (-_ J ✓
v:ith a principal place of business/rn'denc
CIO llCl(rby CCR1Ij', tillaci t11C jl ]iL i?ii'l pCII ]ties 01
O I am an employer providing tflc follo•.vint_ v'orkcr`s colnpensauon coves e nor my
cluplovet;s W0147I19 on th]1 )Job:
(Irsu-anc, Company) ( c c,Nurnbcrj ---- (rte r mien Date)
( j I am a sole proprietor, genera c:an r c cr hon:eo,�ve: Ici de one) and 't:a.e hired
the coni.actors lzstec bei0w -�,'ro k er •- e ^ial s
-orK s coy:.v neon
(1`:a-me of Concmctor) (I °'�_^,.. C:. ConncY i'r _'11T?-' r-,.� c -
n� n -Pc?ic; NL.Int`Cr) ;c- Dat.,)
(Name of Conti-c"cr) -- lLnsur nee Cow _rr,r�Pe!ier Num, Q p ...:ioa Date)
("Name of Coaamctor)
- (Name of Cont--actor) —- (Ins�ranc� Cotnr_.}'1Polie� Num��r) (L;:Di itir:Dare)
(.^.IL�G7:..d'�tt]cct of S::LG{;:::r.^r-.�-..'-,7:^.-LP�.i':;::-M;ta[:Ct'--;•1["'••_': li < -
I t1ITI :;olC pro pi1c, ii.11 iii?,' n 711' ;rl� 1o1 ;IIC.
2iI] t1 I:oIIIe (;A,''Il 't)�.:C`iI11h ��)( i_: �' `,'tilf
NO_rE:please L-c awzrc tirzt s-:ilc
not t cce tli n thrco unite in tti dt he];:r.•,r, rc:
c'ployc3 un cr t}r tvoa:ri:cc -,._..cn 1.152 •:(Sl
•.•; ,�r:�<� '- .'-�.• ._;::cr.�,y a hnricou-rs`:cr a L!�'_,c tc p-rn:r. -. `tia:c'
]cgal rtawz of cn c:xployor uz)d tt c Wociur.co,,Iion .cL
I undo stand thL a co,y of Z. s cuy bo fo nrci to 11�DY tzr rL of InriluriJ A 6&=&Oir w of for tfx
covcrAsc vaMctioa and th_t L•.ihue to c-c c co uz.A" cciM 25 A of 1.tGl.152 can 1c^d to the im situ c:�in-1 pc•.ali:
C' =i-Tting ofa fur_of up to S I.500.00 n:r"'Cy of up to nn-)-u r:-.j cavil p' n 16'in f'-,nn c•f+S!c,`}'ni.(h? trj
Lre a(:;10,0,()(J a dsy
t oc ;,.u:rstal u.o c Ay
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S�CT10N 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : > �/
License Number
Address Expir tion date
Signature Telephone
l
9�Reg s er° e1'iomelmpro�eme tContractor 07 Not Applicable ❑
06 -� �v�ti l ads
Company Name Registration Number
/3 :2 r2i 16
Address Expiration Dat
k 1A A16:,-1p MA ON 21L Telephone
SECTIOFI IO WORKERS' COMPENSATION IN.SURANCE.AFFIDAVIT(K.,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...... ❑
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
s w,
SECTIOND�SP.T10NIOF4PROPOSED WORK(check,all aDD11 cable)
� �«,��,a� ' '�ka*��','�,�„ ...r�a, ; .,.a.,. ;•;;�, ' ,�„�.�,� ,�ems.
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ )
Brief Description of Proposed Work: 52,2Z'7 6JVIt�e> STS / c'Iiy PL j
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0-Sheet 0
_e-W-3,05'.u a o aAA° tMR to>:exis§Vhk housinja�ldte therf 11wi:
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
SECT OT�I 7A OWNER AU HORIZATION TO BE COMPLETED WHEN
OWNERS A°GENVOR CONTRACTOR APPLIES.FOR BUlIrDIN'G PERMIT
as Owner of the subject property
6,--7 to ac, on hereb authorize
my behalf, in all matters relative to w k authorized by this building permit application.
Signature of Owner Date
as OwnerAr d,A-gent"
hereby declare that the s ements and info mation 6n 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 gent Date
I
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
i
i
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 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:
City of Northampton M
Building Department
t
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 t�
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A�N _ 1(DWELLING
SECTION 1 SITE INFORMATION
This section i a np
cople zce
1.1 Properly Address: �� � �6C M
—( '(®6�L Ntats a Ca
Zone Oren ay Distr�crt
EEm St.D�stiYtt C8 District
SECTION 2-PROPERTY-OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Na a(Print) Current Mailing Address:`_ 1,A—
L-�- Telephone �S((
Signature
2.2 Authorized Agent:
Name(Print) �;� Current Mailing Address: / (�
7
Signature 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 l (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 Of iicial'Use<Onl
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
294 BRIDGE ST BP-2004-0847
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-076 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-2004-0847
Project# JS-2004-1257
Est. Cost: $653.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sq. ft.): 6621.12 Owner: SQUIRES JOSEPH D&MICHELLE L
Zoning URB Applicant: DE Sheppard Roofing
AT. 294 BRIDGE ST
Applicant Address: Phone: Insurance:
224 BERKSHIRE TRAIL (413) 587-0092-0
CUMMINGTONMA01026 ISSUED ON:315104 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 1 SIDE OF GARAGE
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 Occu anc Signature:
Feel e: Receipt No: Date Paid: Check No: Amount:
Building 3/5/04 0:00:00 242 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo