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DEPARTMENT OF BUILDING INSPECTIONS /
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 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 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
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m DEPfuZI'?fENT OF BUILDIJ G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Vass. 01060
WORKER'S COMTENISA'T`ION INSURANCE AFMAM
-------------- � - -tom �---------�.---------_._..___- - ---- - - __
v:ith a principal place of businesslrenidellce t:
d0 hereby cer4iftir, t1ncle.i rile pains ,:nd pcn ltics oi perjury, :.hat:
( ) I am an employer providing file follow"MC ,;orr_ers compensation coves or rn_y
employcc's working on this job:
(LnsuanG Corsi') (Pc�ic,NttrnExr) ---- (Fxriraaen Date)
( ) I am a sole propnctor, general home C)wDer (Clyde one) and .:av hired
t.h:, contactors listed helot ho 11 the :ell ,r:r <rorke�s copen 'eon ,cic.es:
,1vI=c of Corunctor) (llsur anc LCIP^3'1r��GtSCr ��llS71tYi) T?:':'i:'uGii D81C)-
(Name of Contractor) (71ISJrrce Cow�a v(Po!ic Nt mgr) (I `:r ;io Date)
(Name of Contractor) =.z;, raeea irate)
- (Name of Contractor) — (Insumlicz Comr Y-;/t C)Ucy Nlrmb�_r) (E-p!r::tion Date)-
lettaeit
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i i1ST1 <'. ";01C prt)mu,Ur 2il'1 havi; 110 oI! U!"^:iii!; t01 illy.
I am a hol„e owner
;)[C&C bo:awl zc tt'.at%vhf 3,l7!7COt\:YT3 wk ci^.7l ct: 'y t« cl! y
hoe ux-te th_n Urm un?s ir.«L et t e I .,•ti;. rr:i, z u a;'` ^�.'_.,s =rt[t-_:r:t _:t
c.-:ployca uti:cr the tw.,fs cc --:_'i n rte:((ii_! hnc:rco•j-cs`:oral cx cc
Icsil rtatuc of an c=vloyer un<'.er tLn wukcr.Co•i o�iivn?.ct
I undc-st nd di >copy of tlii ttatcr:5t c_vy bo fotw,vcio-j to tI»IYticrt,-xwn:of Indiu!ricl &
�' -, f. _ .l. of a Ste'+`,VcrY Ord' _r.d_
ooaiutm of n rur_oCu to S I,SCO.QO a:.sor i�::)r,�;t•�;�1 n..: to or.- ;� r...j evil xrsltin in..�c IiXrn ,
3 F P } 7 III
f iz of S l OO.W dry I gr-iwl m:.
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Permit __-------____--
_ Map"',
Strnaturc ofi.iccn:;cJPc
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SC�]ON 8 ON.STRUN SERVICES
8.1 Licensed Construction Supervisor:/ Not Applicable ❑
Name of License Holder
License Number
0�e �c _ �'
7
Add s / Expiration Date
Signa ure Telephone 7/g/9<p
Reg s ere ` 'omen morotrerner t'Contracto Not Applicable 0
Coipany Name Registration Number
Z /1�` d 1Jr 1 y�03
Address Expiration Date
Telephone 7v
SECTION 10 WORKERS' COMPENSATION INSURANCE--AFFIDAVIT(M:G.L. c'. 152,;§ 25C,
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"homeoNvner"shall submit to the Building Official,on a form acecptable 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
� �•*.x�'�a-��'� .�: �- urdi"" z�
SEGT10��- S.° P�ONIOPIPROPOS'EDWORK ch ck 11 sa I+cable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolitions New Signs [ ] Decks [ ] Siding[ ] Other
Brief Description of Proposed Work: ` IT os c �•rlS
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll❑• Sheet D
# I us 0 dition to ezistink Kousi`ngg QmpJ he fo1J WMAR:
a. Use of building : One Family Two Famit _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. floodpiain 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
SECTIOT� TIERAUT�HORIZATlON TO BE COMPLETED WHEN
OWt�(E!{SA�iEI C O,RCON"�fjACTOR APPLIES FOR BUILDINGi,PERNfIT
as Owner of the subject property
hereby authorize /3 0 u r� to ac on
my be in all matters re o ork authorized by this building permit application.
Sigifature of Owne Date
I. /D c 'W4') rc? as Owner/.Authorized Agent
hereby declare that t 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.
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Print Na
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Signature o Ow /Ag nt Date
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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 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 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 X —
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
Building Department
212 Main Street
Room 100
Northampton, MA 01060 3 P`
phone 413-587-1240 Fax 413-587-1272
MAI
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DE1 H F I ELLING lit
JUL 1 3 2006
SECTION 1-SITE INFORMATION
1.1 Property Address: Uhrs im g 7b T o ce
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SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2,1 Owner of Record:
ac ui
Na ( int) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
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Name(P Curn5rit Mailing Ad s:
SeY.-/LZ7o
Signature Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building (a)`,Buiiding Permit Fee
2. Electrical (b),,Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection 5'
6. Total = (1 + 2 + 3 +4+ 5) X00 �° Check Number
This Section For'Official Use Onl
Building Permit Number: _Z�r? Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
11 ELIZABETH ST(218 BRIDGE ST) BP-2007-0050
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot.-
rmic: Building
Category: REPAIR DECK FLOORING BUILDING PERMIT
Permit# BP-2007-0050
Project# JS-2006-1638
Est. Cost:
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: hartsbrook builders ,Ilc
Lot Size(sq. ft.): 3615.48 Owner: PAUL STRUTHERS
Zoning:URB Applicant: hartsbrook builders ,Ilc
AT. 11 ELIZABETH ST (218 BRIDGE ST)
Applicant Address: Phone: Insurance:
89 Longview Drive (413) 584-1370
FLORENCEMA01062 ISSUED ON.711312006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE DECKING ON PORCH -NO
STRUCTURAL
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 7/13/2006 0:00:00 $0.001198
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo