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DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR 212 Main Street 0 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 his/her construction sups: 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
� �t�� .:- 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
f
0�.�✓V.NI'TD o��r -
�;
�1�c57 RC}1115[115
D Ef'�-2TME-NT OP BUILDING INSPECTIONS
212 Alain Street ' Municipal Building j
Nor th amp toil, Afass. 01060
WOMCER'S COMPENSATION INSURANCE AI MAVI.T
i,
v:`1111 a principal place of business/retsidcnce
do hcrcby CCrulI} t!lla l" Ll1c pa!,r1S °.iid pc n li_l, Ol pCrJllf}r, i1a<"!t:
)_ am an enlpioyer providing the v;oi`_crs compcnsaU0I1 GOVe:"a`,C I0r to}'
employees working on this job: v
(Insu2nc:: Compaiv) CP clic,?tirumbe;) --- (F�Gir ien Date)
I a-a-L a sole proprietor, gentla con,=_or o: hom. O%vDc: ( rCle one} and hired
- + 0
li GOIluaCtOrS l.ste>r be 0�'r:; C) ii�.., �ll�' in%1-��-,v ., �, CO%?p ;i��Or1
_a_,C of Conmactor) (TRSi'2IIC Cvl ^::[71:�G11'j 11111Il I) T?:: ::uC'Datc)
(Name of Contractor) (7�zssrnec Co��",`'(Pe!icr Nt rarsr) (l :r� .atio Date)
(Namc of Contractor) (Ins �ncc Co n;: p/Polic, Num[f r) =z;, r.a=o Dal,-)
- (Name of Contractor) — (Ins ratic Cotnr�l};Policy Nu.mblr) - (F);p ratio-Date)
l 21II1 a _sole pr pml '_)T <':::1 hav:, no oIic, foi- illc,.
c�
111 <! home Owt1c-
NO" Ff plcasc be atra:c ths; cal oy;r. ._ a _: nco a::_n
not utc<c than throo un?%in o; ;:3= ur c: rt Lhaao 2 exl cersal2 y o. :::_r :o h
cntploycs utidcz t}r tvcr�, z cczx :e;i-n Ps ((,t-!`2 !(Sj!,a,:Ilcaair_;;by n honum«-cw for c Lccu cc par ti:r. .rtie
Icgil ztituc of an amployer un We l;c1a Co2,xr alion .ci
I undcrzt.nd thi:a copy of this[cite ai c:+y bo fo«unrcir.!to L»fY.txi tZ cn of In ius ri>1 for tha
cover-tsc,vrrMcmtioa and that f_iltuc to 25A of MOM,152 cw It-d to the impozitio.-t c,•"r�i_1 pct:all:cs
—iati�g of a firx of up to S I SCU.OJ n:t1' r i^::ri cz ;1 of::p to cr.-}- ,-.i civil pezuttia in�c fcnn �`
of n stc:+'� clZ_Oni=-r-J 1
farm CC S100.00 i day igi-in:1 rn- -
_ �cccSq%uurri:sl tt is ct:ty i
Jis Mturc of:.icon:x:Jl'crmitt<_*,
L
SECTION 8-;CONS7 RUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
�9R g s eyed .ome lmpr.''ovemert.-ontractor Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10yINORKERS' 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...... ❑
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 fe-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.
XHomeowner Signature
R -
SECT,,ON S. DE5 R: P«TQN OF*PROPOSED;WORKIcheck a 1 a` laca ile'. [F °N4'W
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors M"
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ J Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll❑ • Sheet❑
6ifi_, ew ous
0008—Witi existing°h uo sin'gcompet et�ieforlowane:
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
SECTIUI,�I7xzOWNER AU�HORIZAl ION "TO BE°COMPL'ETED WHEN
OWNEkS°AGENTORCONTRACTOR APPLIES FOR BUR DING PERMIT
I' as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this wilding permit application.
Signature of Owner Date
I' 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.
i
Print m
Signature f Owner/ gent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This colurrm 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 %
(L.ot 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:
o
II
City of Northampton
Building Department
212 Main Street "
Room 100 r
k
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,
Thisect�a ►be cam pleted�by taffice
1.1 Property Address:
ilnit
V C)r'1 Vi /�1✓yL. � '1 �� Zone rlay Di�str�ct
NBm SI.'Distrsct Q�StCICt r
SECTION 2-PROPERTY°OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
7
Current Mail' Addres
Narpe�(Print)
(� � Telephone
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)EEstimated Total Cost of
Construction from..6
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 Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
37 OLD FERRY RD BP-2004-0665
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-248 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0665
Proiect# JS-2004-0954
Est.Cost: $863.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 10018.80 Owner: NOWAK ADRIAN&PATRICIA
Zoning:URA Applicant: NOWAK ADRIAN & PATRICIA
AT. 37 OLD FERRY RD
Applicant Address: Phone: Insurance:
37 OLD FERRY RD (413) 587-3959 0
NORTHAMPTON MAO 1060 ISSUED ON.1215103 0.00:00
TO PERFORM THE FOLLOWING WORK.INSTALL KITCH WINDOW REPLACEMENT
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 Sienature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 12/5/03 0:00:00 1534 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
37 OLD FERRY RD BP-2004-0665
GIS#: COMMONWEALTH OF MASSACHUSETTS
MW:Block:25C-248 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2004-0665
Project# JS-2004-0954
Est. Cost: $863.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grouu: Homeowner as Contractor
Lot Size(sq. ft.): 10018.80 Owner: NOWAK ADRIAN&PATRICIA
;TR A Applicant;_NOWAK ADRIAN & P.ATRICIA
AT. 37 OLD FERRY RD
Applicant Address: Phone: Insurance:
37 OLD FERRY RD (413) 587-3959 O
NORTHAMPTON MAO 1060 ISSUED ON:1215103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL KITCH WINDOW. REPLACEMENT
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:O W 7-/G
THIS PERMIT MAY BE REVOKED BY THE C TY OF NORTHAMPTON UPON VIOL OF
ANY OF ITS RULES AND REGULATIONS
Certificate of Occupancy Si nature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 12/5/03 0:00:00 1534 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo