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DEPARTMENT OF BUILDIT G INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '` S'0
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 super ..,;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 hour), 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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DEPAJ1 TMENFT 01' EUILDMG INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORTCER'S COMI'ENSATION INSURANCE AFFU)A�q-T
k,Mt
(liters°Jccrmitre^)
N:'ith a principal place of b1IS1reSsfrCs'd^I1C--
f
do 11Creby Ccr-ff', La:' I- tllc gams :ncl pen ltic i o pc;1�UI�', t.11i!t:
( I aS11 10 enapioycr providing the iollov'J1I]C ' :OI r_Cr S cot l)msabon cove'ra. - Irti'
employees work-infg on this lob: _
(Lasiranc.- Compam') (P c ic;Nur_tbcr) ---- (F>-p;r.don Datc)
( j I a-m a sole proprietor, general C-:M1a-,CTor c,- horleo'.11ver (C'uCle one) and lla.'e nirec
t-11C contractors listed b e i o w.;'1.0 il�.' t�lE 10i1r ;, .j PAC ^ e ` t;�
^il orri coL p nsaon -�,_ .es:
(1`amc of COrumctG �L C CCIr^".:i i)
r) (in n �,t clicJ Nusn)Y �'; c- Datc)
(Flame of Contrctor) -- (7�tslr,rc COmr_.v/Po!iet' Numb--r) (E?T ration Date)
(iN'ame of Contractor) — (InsuTmnc�a coo—,113y/PoGc: Nu-n?r,Ir) _.\; ;-nc; Dal,-,)
- (Name of Contractor) — (Ins(lranct COInT�r—v/1'OECY Num>y-r) (_];;ni-:tie'Date)
C I i1IT1 GU1C l?I'UpI1CtL)i i!iIa l]aV t10 OIIC '..Jr�.liT`; fo1 I11C.
� � 1 :?ii1 �? 1101?]C 0`�'?1Cr IiC1-:a`IT]li'" ?ll .,. • ' '
NOTE..ptc-sc be ftwzrc
not tncYe lh:n throo uui+ls in t,J-:.ett he I.7,1 :'.1 or o(i h:
ca'.ptoycs ur cr thr twri:cfs rte .-;_.ica:.c (< t S'
`cr a Gcc:;c ct p:ra:r:::
legal rtatuc of na omplo)w under ttto Wcv{;c1s Coa e Ilion!.cL
1 un&-=I�ad the a copy of thij uatc:s1 cv(y to for---dtd to tin LYt nrtzun of Iii riel M1l�t:a CiLao of 1: +�c -o for tix
°ovm Sc veriTirtioo and that f it TTC to cast co,.-rg ur3 c�.iM 25.q of 1.tGl,152 can Ird to the Tnpnsiiio +f c i._1 pawl;:s
Misting of a ftrr-of up to S 1-500.00 nn'Jcr i^:pr:� tti;•!cf;;?to nn }- a:.j civil pcnzltin in r fcr n cf n S!r.+`;s -ri_<} 1=and a
f ra oC S 100.00> day ig:.in:1 m.. .
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Pcrinit Ntllnlrs
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SI_CT OMe� . O'NS;T,RUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Re . e e nm. Ve en. n rta.c:o Not Applicable ❑
`l,)-4U'D 'NJ C'Nr2 303
Company Name Registration Number
� ( 1-=f 1 -,23 -K
Address Expiration Date
Telephone C 3T4T-
7ECT � w0 KEGS' COMPENSATION 1NS�llf3ANM 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"homem-mer"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
'K".i• ?f ', {..f ie� rAq£•u,...:feb 5 '. 'L- 4. 9
ST10 - P O 4FiOPOSED�1►YOF3K che,ckalla I�caiile .
IF4OW:!'.Si.'�,u'fAV^9iuw"._,
•3�'h.''..P. �:+, .:..: �':,,. ...,. ',".''n§"mz'�'g'k.: ..kk".'�:. .::.�'k a.: w{�- nvi xw.. �' Y� fi� ':_?
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[Vr Other [ )
Brief Description of Proposed Work: _J.A'
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll D- Sheet D
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 Nc
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
E� ® 1CY g l� �tjRIZAT)ON TO BE COMPLETED_WHEN
SOW S • , O _ CUNTRA�CTOFt�Ar`PPLIES FOR BUILDING PERMMT
as Owner of the subject property
hereby authoriz DA-ij o) + Z to ac, 01
my behalf, in mattes relativeAo wor authorized by this building permit application.
Signature er Date
Qk as Owner Zthe�es�myy
hereby declare that the statements and information on the foregoing application are true and accurate, to
knowledge and belief.
Signed under the pains and penalties of perjury.
�n L
Print Name
Signature of 0 n 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
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:
of Northampton
ing Department
2 Main Street
oom 100
VA or am ton, MA 01060
pone 41 7-1 40 Fax 413.587.1272
�trseE�'o�s
APPLA � �Y NSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE'INFORMA710N
..
isisec oornp, +e ffic
1.1 Property Address: a . F
�� �I<Z►��,� S� Map ,;
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Elrif;•.t�`D s't`rict '��" �_. .,..._.._ .B�Dts: Ft' .m. _�'�
SECTION 2 -'PROPERTY'OWNERSHI.:MUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Ai rized Agent:
A5,i"D i\J
Name(P ' Current Mailing Address:
w3-3g -
Signature Telephone
SECTtON..3y- ESTIM ATED CONSTRUCTION
Item Estimated Cost (Dollars)to be Official Use�Only
completed by ermit applicant
1. Building J� cc�� (a) Building Permit Fee
2. Electrical / (b) :Estimated Total Cost of
.,onstruction,.fro:rr 15
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 On'I
Building Permit'Number: Date'Issued:
Signature:
Date
Building,Commissioner/inspector of Buildings
STS', BP-2004-0217
GiS#: COMMONWEALTH OF MASSACHUSETTS
06 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0217
Project# ]S-2004-0316
Est.Cost: $10000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor., License:
Use Group: DAVID NUNEZ 128305
Lot Size(sa.ft.): 3267.00 Owner: HART EDWARD J&JOAN M
Zoning:URB Applicant: DAVID NUNEZ
AT: 25 ELIZABETH ST
Applicant Address: Phone: Insurance:
41 BRIAR HILL RD (413) 268-3395
WILLIAMSBURGMA01096 ISSUED ON.8125103 0.00:00
TO PERFORM THE FOLLOWING WORK.INSfALL VINYL SIDING
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 Occupangy Sienature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 8/25/03 0:00:00 2187 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo