25C-228 Q�VILAMpT
Titli of Nortflamptall
� � �t ASSACI)li5[tt8 '
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main SU-eet 0 Municipal Building
° e
Northampton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under
. 780C� 108.3.4 to
act as i,is/her construction sup:,. -isor. The state defines "Homeowner' Person(s)
who owns a parcel on which he/she resides or intends to be, a one o hfw family
dwelling, attached or detached structures accessory to such use an or farm structures. A
p(.rson who constructs more thar. oric home in a two-year period hall not be considered a
home owner."
The building department for the City of Northampton wants/11y 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 complian4e 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 (befor ece pour), a rough building inspection (before work is
concealed), insulatioriyinsttion (if required) and a final building insuction. The
building department req res these inspections before the work is concealed, failure to
secure these inspections ban result in failure to obtain a certificate of occupancy
until the work can be insp!LrIted.
If the homeowner hires other 6ades to perform work (electrical, plumbing & gas) the
homeowner will be responsible t` make sure that the trades hired secure their proper
permits in conjunction to the buildrgg permit issued, and that they get their required
inspections. Failure of the individual`tfades 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. r
Date
Address of work
location
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eoverise vcnfiGlioo n.:ai tivt L-ilt:r-c to!-curt cUVrtn�o uc.3a zcctirn 25A of h1C-1,152 can Iced to the
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SECTION 8`-CONSTRUCTION SERVICES
8_1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : _�lo_w//c p!_ `Nu Number
"
License Number
Address f
9 7 ��� + Expirat on Date
-1-n A�-,-��--/ - - '57, ?--OCJ-�l --
Signature Telephone
9i'Registered HomeImprovement Contractor �,,,r , ,,u, , , ,,,, .. Not Applicable ❑
_ z
Ctfmpany`Name Registration Nu ber
Address Expi ation Dat
Telephone_2 0 S 1/
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...... ❑
Vl-
mel wnerzwixemp lon
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 fur 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
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable
New House El Addition ❑ Replacement Windows Alterations) El Roofing
` --
Or Doors F1
Accessory Bldg. ❑ Demolition❑ New Signs [ ) Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Wok - _✓ �_ -- -_
Alteration of existing bedroom -- Y'es No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement _ Yes No
Plans Attached Roll ❑ Sheet ['
6a. If'New house grid or addition to existing housing, complete the following:
a. Use of building : One Family —_ -- 1 v o 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 fora; attached?
I h. Type of COnSiruCtlOn
i. Is construction within 100 ft of wetlands? Yes No. Is construction v.;/thin 100 yr floodplain _ Yes __No
I. Depth of basement or cellar floor below finished grade
k. Will building conform to the Buuilding and Zoning regulations? _- Yes -- No .
I. Septic Tank__ City Sewer Pr ivate well City water Supply
SECTION 7a -OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, _ �!� - �'t.� L•1C-Z asw r ne of subject property,
_ - -- —
hereby authorize — 1 � "mod/" v" - I �/�o C (,�,-� �G � -- - to c, or
my behalf, in all matters r ative t ,+k authorized by th s building permit application
Signature of Owner Date —_
e as Owner/Autho -zed.Agent
hereby de are that the stat ents and information on the foregoing application are true and accurate, to the st of m
knowledge and belief.
Signed under the pains and penalties of perjury.
}7/V!6 ----------- - - -- --- -
Print Name
---- ------
Signature of Own e -Agen Date =
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: _ ---
_ __ _- --- ---- — ---- ------ --- ------- rtrpen sego "
� Depa tau finly
Northampton Status of
u i 11 Department Curb Cut/Dnvewa h ermlt.
n Stree! Sewer/SepElc
0n_ 100 Water/Well Rvilablllty'�
`j � a'�ortl I li ,on, MA 01060 Two Sets of Structural Plans
9
I pI10ne 4 i ')c i y'` ax _5 `, t . PIOt/Site
LIONS OtherSpecify'
- - _.
, = v
1
;__ c�11 ATt�71J
TO CONSTRUCT ALTER REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
--
SEC
---ION T 1 - SITE INFORMATION
----- ----------- - I - - -- - ---------- -- - ----- ------- - -
1.1 Pr-gp This section to be completed by office
erty Acldres_s
Map Lot Unit
Zone _ Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 0 ner of Record:
d
������ j'C• _ ,Sgt—"of
i
2.2 Authorized Agent:
NatIntl d
,
Sign
SECTION 3 - ESTIMATED CONSTRUCTION COSTS I
Item s}imated Cost Dollars to Official Use Only
c-�i- Meted h - it ophcan?
� f?
i �3U IdinP j (a) Building Permit Fee
_ 'i� tmated
To Cost o`
onstruct!on irof7l -
3. t r muir g Building Permit Fee
4 irCfldUC iv 1r,
5. Fire Protection
6. total = (l + 2 + . + + 51 �� (� Chec� Number
- ---- - - -
- - -- ---
This Section For Official Use Only _..
Building Permit Number:_ Date Issued:__— —.----
Signature: ----- --- - ---
�� Building Corn missioner/1nspodor of Buildings Date
T.
BP-2004-0160
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: BuUft
Category: BUILDING PERMIT
Permit# BP-2004-0160
Project# JS-2004-0239
Est. Cost: $1302.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sg.ft.): 4399.56 Owner. SUBOCZ MATTHEW K&
Zoning URC Applicant. DE Sheppard Roofing
AT. 45 WALNUT ST
Applicant Address: Phone. Insurance:
224 BERKSHIRE TRAIL (413)587-0092 0
CUMMINGTONMA01026 ISSUED ON.•8112103 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE PORCH ROOF
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 8/12/03 0:00:00 745 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo