25C-200 (5) O O
Gity of Xort4auipton Z I
�ITA55AChlt5ttt5 ''
a-, DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '�,
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as 1-,is/her construction sup%-,• 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 buildine 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
a
�"0
�, a � C1,i;t�I x1f ��cr�-tlJztttt}lfcrtt __ �.
� 6 ��i�lFCl(n5(It5
`-7
m DEPT RT MENT OF EUILDD) G INSPECTIONS
212 Alain Street ' Municipal Building
Northampton, Afass. 01060
WOPJCE,R'S COMTENSATION INSURANCE A + +DDANIT
1 -? siA.�n} �-
(lICtiP.
%vIth a principal place of businesslres ccnce !:
_AR
CIO hereby ceTIL11) un:( r the p<ns ,°.aci pen;hies p;:rjury, Lhai_
(Loje�a_m an employer providing the cllo',viia_ '.;oFIKu s comnensauon coves z.e or my
employees working on this job:
45 CIO
(Las,j c- Company) ( c_c:Number) (rte pir,:don Daic)
j I acs a sole proprietor, genera c:an c cr homco,,vTSe: (cLcle onei and gave hirtd
the Cont:actors listed below v,-ho
• t. � :.� •���orKe s cor;l� neon :� � �s:
(T:LLL➢C Of C011tIMC10') �nS�i�11C: I�OIa^?a•.',T'pI1C- I'1P�Tlt'Cr) (�= .:.�o-
f c.
(Name of Counctor) -- (7nsJr rco Comp .:vfPoiic �uncr i) (I �i.aiioa date)
(I"tamc of Coatractor ;I ^,� -
ti� ..tic.. (_.,;i; :m.,ir'ol.�, NuII?lxr) �_ rti ,�a.,,_Date)
—(N1 3me of Cont--actor) — (Insurance Coa],-la;polier Numr=r) - (E�:ni-:iio:.Date)
hav_, no
(, )
2111 a hoilic
not umee th_n thrco ut:i+s in ct lx f -z a:-rcu;c:,z Cr a; :_:.s c•-t c. 1 LhCCO e c rr t�err:ily a=r::;:::: h
cZ1pioy,=3 uty"icz the_ ((,11152._.c; ho:•irou�rcr:`cr:GCC_,c is
]rszl natus of an o�loyx un�er t::n Wcv�c.'.io.2�;>orr�t.ian:`.cL+� -
I unde.-Ttaad th,t a copy of qt crate:a•cuy bo fo tivn-ciod to 11n IY_i n a of Ind,istri j Ao66 ,&Cffi w of for tax
covG,t vctilc-lion a d tltt f rc to to rc co:-tM uc 3: �,iM 25A of:',GL 152 can Ic-d to tlx im;�siiia of c :^1 pct sl:s
misting of a fur_of up to S 1-5o0.C�J n:1 r i^;u yr Zti;tt of::�to cn-)-`r..:.1 civil p'_MI=in do Icnn Of
Lrm of S 1 QO.W a CLty igain:l tnc. -
ccc S�:ut zntai uac v,1y
j!1—_ 1�tIiII I _
,t.tly�t
,51-nn to . .••-------1 , -..__ E
AV'
r
k .r,w,.,.:. r':s`;•,7 k..;° 'ors:
SECTIONS D 1 1B
IRMON ROROSEDVORK check 11 a lica�Ie �
•' '9"Y .f .,.. '','_ +acv'' ..".R..u..5:. a_ �t`�'i. -.= "rSk'ii-ii.'•'w - - •k.v L iX�:^'J..3�^r"yv'E`'.
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding Other [ ]
Brief Description of Proposed Work:
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
6aM- ' e�ou�&O a"ddi:tton�to 6istinR7 housrng , lete th efoll:[n7g,:
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
SECTION7a 0►11NERAUTHORIZATION TO BE COMPLETED WHEN
R!_APPLIES FOR:BUILDING PERMIT
as Owner of the subject property
hereby authorize i A-) L /J ���f� _ to ac;. on
my behalf, in II matter fi work authorized by is building permit application.
/6
Signature Wnw Date
Z' 75r4iJ as QWPer/.Authorized Agent
hereby declare that the statements and infor lation on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under�the pains and penalties of perjury.
G�l7lJ I •cJ �v
Pri
rtL.W,a m e
Signature oTr/Agent Date
._..........
S,ECTiON 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: y� Not Applicable ❑
Name of License Holde L 73
T77 y�� License Number
Address Expiration Date
Signature Telephone /— -j'-
Reg s e e brne mp ouement tr ^+^• Not Applicable ❑
13 cA 4 Al _TA) �--
Company Name Registration Number
Address V Expiration Date
Telephone
SEGTIOH"10 WORKER$' 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 e 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
Af
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
i
i
Lot Size
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 µ
Building Department _
212 Main Street
Room 100ra
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Proerly Address: t "Th
u is section to)be Completed byfFce
uK
05 P
MaP 4r Loti VIA
✓V�/
C)97k A Y'K To ✓� aiier+etslay D�stnct.
r
k
3
;Elm St iDistrict ,` £8 stnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: 6,/ Clete..5 r Ag! o;- Mrtn
j; OJ C/�!!14/ A) '23 /?'d2/iU t'-
Na a(Print) Current Mailing Address:
Telephone
Sign 're 2 lj" aZL-
2.2 Authorized Agent:
Nam int) Current Mailing Add s:
.s"--28 `z'14,7
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 ,.� (b),Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Pee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 +3+4+5) /3 /3a-`� Check Number
This Section For Official Use Only'
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
LINDEN ST I BP-2005-0060
GIs#: COMMONWEALTH OF MASSACHUSETTS
is Mk.25C-20 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-2005-0060
Project# JS-2005-0080
Est.Cost: $13132.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq. ft.): 6969.60 Owner: CHAPIN ERIC J&JANNELI N
Zoning.URC Applicant: B & R Siding
AT. 2 LINDEN ST
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON.7115104 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 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 Occugancx Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 7/15/04 0:00:00 19411 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo