25C-160 (4) O¢��MpTO
of Wort4aimpton
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DEPARTMENT OF BUILDI7,TG INSPECTIONS
INSPECTOR '212 Main Street • Municip-tl Building
NordiamBton, 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 sup(:-,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 fami ____
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 eegulations. 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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4 c� DEPARTMEI-I- OP BUILDP\jG INSPECTION'S
212 Main Strcet ' Municipal Building
Northampton, Mass. 01000
wOruccR'S COIAPENSA770N LNSURA.NCE Al ,II�AVIT
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', (Ii ccusxJperm�tfcc)
v.,ith a principal place of businessfresidence zt: ---- — - -
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_ (phone')
(su�t/ci ty/staSda P)
do hereby cerrify, under thc.pa-iris and penalties of perjury, :hat
( ) I
am an employer providing die iollowinp-.vorkces coinocnsabo, cove��gc for Im
emplovices worUng on ties job:
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(Lnnlnn= Comm r) (Polio: Ntrnbccr) -- (E:•piratiorr Dai)
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( ) I am a sole proprietor, general contractor or homeowner (circle one) aDd have hired
the contractors listed below who t-Lave the `olloiving worker's coipen_tadon policies:
(11+^II]C Oi COnr^Ci0") (IRSl r3ncc Coinpan)•fhGUC-i ?ill m=� ) --'•_)1FJ:3n? ��ILC}
(Name of Con[raclor) (inssrancz Comp \Limon) (-EiDir.6on Date)
(Name of Cour aao;) (Instuanc:. Company/PoUq- Number) (Expircioa Daic)
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(Name of Conoaaar) (Iasurmcc Comcan-y/Policy Numbs) (Expiration DaIP)"
(attAcb zdu-�or31 c5c.c,if nccc3al•to c�cu�-iafortn�oa pertainin.�to a
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am'a le"proprietor and have no one worl3ng for me.
(- am-a home owner performing aH the work myself.
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NOTE:p(esc lx ewsrc tfi*•uiJe bemcoµvcn ui>p mxplay PcrLons Lo i• —^^ -rwo c rcpzir w-oric oo a d%,mU-Z of
apt mat th n 'ter>�r�is u�eb the bocnoovrvcr r,=d-,or cc b-crvra6,apuru==tba-es c c nx c=a.r_Uy oee::dc-rc i to be
:100yes the--kd:cc -+co Act(GLI52ss I(5)} ppti=.6on by a bommaaa fer a Gem-or permit M=Y evrd—tbe
Icp1—of ea-=Ploy-under dip Wo,+xec Coatp-om..aioa Act
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[undea...ad tiles x Dopy oC thia aztemcct m„y be f«�..utied to the pcgartmcn¢of In�tri al Ac�d�ssa'Offioe of Ir>�+r��+for tSa
oovense v C=ioa acrd tYu L-i=to Lc0v )W%vM�c undo snetioa 23 A of MOL 151 C=led to the impozi iw of aimia+l pcalwc s
000aisssg or a fine orup to s 1500.00 a'Wor 6.P to of up W Doe year e.od ai j pcnnhie in 6c form of a Stop W ori;Or'd--ad a
fim 0(S 100.00 a day LPjn:a mc-
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PcrMit NL1IDtKS _
Gl V "Map-" Lot K
S i t f Li c cmi — --
SECTION 8 CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
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s �-q 5. ' i�"3'>—",cr3 ''�
9ternsfe tome tinprovetrrenContrator ..,� Not Applicable ❑
Company Name Registration um er --—-
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE'AFFIDAVIT(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...... ❑
ll�:n H�m�Clw �e>l�t�"��►�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 hue 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-vear 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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SECTION'5--DESCRIPTIOWOF>PROPOSE,D WORK(check all applicable)
New House ❑ Addition ❑;. Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors l]
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C] Siding[[3] Other[o]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes y No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
Nev�thonse hL , af#ton�oU.x�stinctho�slng:;complet6the:�o fouv>tng:
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. Di nsions
e. Number of stories?
f. Method of heating? Fir la s or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck nergy 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
SECTION'7a OWNER AUTHORIZATION-TO;BE COMPLETED WHEN
OWNERS AGENTOR CONTRACTOR APPLIES FOR,'BUILDING PERMIT
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.
Signature of OQFar 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. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed jE d by Zoning
mn to be fil led in by
Department
Lot Size
Frontage #
Setbacks Front — `' I
Side L: E R:' U R: —
Rear '
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved ! ��
parking)
#of Parkin S'aces
Fill:
(volume,&Location)
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A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:` r
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book Page and/or Document
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES , NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Building Department .
212 Main Street e
Room 100 ,
Northampton; MA 01060 :
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, R, V�',E R E ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
The sects n to be completed by office
1.1 Property Address: _
,< /� _1 - �',� •�..._. � �a�t`i� 'ot , "f Unit
0 Y(Au r ' Dc^T ns rT T
C) t&n
�Z�ne'""'i" Overlay Drstr�ct
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Elm St Qistr�ct _ GB D�stnct . .
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED'AGENT
2.1 Owner of Record: f 1 ,,
G 1/1✓1 C UAD i t Z-U �J V Vt1 Vill,10
Name(Print) Current Mailing Address:
z Telephone b 7
Signature
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 (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from` 6
3. Plumbing Building Permit Fee=
4. Mechanical(HVAC) is-� +�
5.Fire Protection
6. Total=(1 +2+3+4+5) O O Check Number
This Section For Official;Use Only
Date
Building PermitNumber Issued:
Signature:
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Building Commissioner/Inspector of Buildings Date
4 ORCHARD ST BP-2005-0691
GIS#: _ COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C- 160 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Peru: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0691
Project# JS-2005-0944
Est.Cost: $500.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 14897.52 Owner: LOMBARD JOHN&ELIZABETH
Zoning:URB Applicant: LOMBARD JOHN & ELIZABETH
AT.• 4 ORCHARD ST
Applicant Address: Phone: Insurance:
4 ORCHARD ST
NORTHAMPTONMA01060 ISSUED ON.113105 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL PELLET STOVE
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 1/3/05 0:00:00 292 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commjssioner-Anthony Patillo
4 ORCHARD ST BP-2005-0691
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C- 160 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildiino DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL C.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0691
Project# JS-2005-0944
Est.Cost:$500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa. ft.): 14897.52 Owner: LOMBARD JOHN&ELIZABETH
zoning_URB Applicant: LOMBARD JOHN & ELIZABETH
AT. 4 ORCHARD ST
Applicant Address: Phone: Insurance:
4 ORCHARD ST
NORTHAMPTONMA01060 ISSUED ON.113105 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL PELLET STOVE
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 Deaartment Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA N OF
ANY OF ITS RULES AND REGULATIONS.
1 '�"
Certificate of Occu ail Si nature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 1/3/05 0:00:00 292 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo