25C-242 (2) �Q'ZHAMPIO ,r '
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DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building '
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 iris/her construction supc�, ,• sor. T he 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
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 M,—1
Address of work
location 'tz t �G E (5i'13 eF_i
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D@PAR1'I,,,EIJT OF LUILDDJ G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S COMI'ENSA'nON INSURANCE AFFIDAVIT
(1 i ctins^�rrr u1 i t iC^)
principal place of business/reSidcnce
�strceU'ci .jp)
do lleic,)y CerL11-v_ t!11C' I Llle t)a ills ::ii7 pC i1 l !e- �i pc;f�111�1, :Ili!:.
O I am an employer providing the 1,0110%,"Int •.<)rr_ers COIl]pCnsation cover C or 111y
elrlployees worldrig on t?1is job:
(IlLn>rana Cocypsm') c cr Nunl>cr) ---- (F}. .irr tion Date)
( ) I awl a sole proprietor, general contiac-cr hoaleowce: (cycle onej and tla,:e hi td
thic CORtTaGtOCS listed bCiQvi ill iQJ " v;o kP,-2S commtnst ion -O!iC:Cs:
(Name of Contmctor) NwnLYr) (L>::irr:aen Datc)
(Namt of CoLn=,or) — 1711SJ P-C { C�1D i�'/�G!tct' \ I it/f) (�:`:v'::'ailOC Date)
0""ame of Contractor) Jnsl:ranc Com, np/i'olic: Nu1i)txr) =s,.s doo 1:-aie)
- (Name of Contractor) — (Ias1 ruic^Color ,)lPolicy Nu.mlr2-*)
l 1 11111 a 'sole proprle:C)i Z1,"J }I iVC 110 one f0+ nle,.
?ill <? home ev1�e-
NO"rT:plc-sc Lac a:.->.;c tls;xi•i}c txcrc:���:r_ra.��c r,�l:-; i}—.=�:n:q::�::,t:�anc�cz._::n:cv'm cr:rpau�� ,....._d.�cilir:�c.
not utoce th_n throo uni+s i:,%,i--d•hc or oo I. U.::s zo•_r cn r1 LF :o c rr_{�S-tally a :`:.'!:;':c t`
cniploycs ur.'. t}tr-tvc;l:f:cGrx-=:--:::i-n x (5) ,a+: ._a:icn by a ho:a o:: `cr a Gcc c cc p-ra:i::: rtic
legzl clams of as oaxployec unu' tiao Wo kc1t !.cf-
I undc-:Ixnd Iha:x copy of th:i cIatc.:s=rv.y bo Corxnrciod to II»IY.Siortzwi:of lydus:tinl M�I,a:.�Clio°oC i:::+_+c��for t1x
covcn&-e vcriGC:,iioo and that failure to!-c-r- 25A of?.(C-L,152 can Imd to the ir"P-ifiol of cr-viral[cr'zl;:=
comisty g of a fu)"of up to S 1.500.00 n;t1'c< of,!,to cr.:)- t:,j civil,>cm)tic3 in to fi, 1 c•(
Lrz,of S l 00.00 a day i paina m- -
_ ror&gw1Tm tat u>•e cr:ty
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Sl-naturc()f;.ic�u rJ1'crmi,tr; !
S€CTON 8� CONS# RUCfIQN SERVICES
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8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
egs a bt7a .mpg ,.e: "en. . on'#racEo Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTI4, 10 WO �E RS' MPENSATION NSUNCEAR FFIDAVIT(M ML-c 152, § 25G(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 buildine 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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SECT,o�±15D�5C�2fPT�lOiJ `F�PROPOSED��IIORK cMeckall
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 0 Renovating unfinished basement Yes No
Plans Attached Roll o. Sheet❑
6a,_ ` ems_ o _: a""�d.ition�:to ez=istingh�.ngg�c�om=p� �h"e�llowrn�
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
'SEC�'C,�OT( ���WI-ifER��U���HO�RIZATfON TO BE COMPLETED WHEN
OW.NfF�SE CONTRACTOR APFLhES, FOR BUILDING PERM'1T
as Owner of the subject property
hereby authorize � � i i to ac:. or
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner 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.
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 St
Fronta e
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 V 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:
City of Northampton
Building Department
212.IMain Street
~= Room 100
Nor'tharnpton, MA 01060
OCT phpn ,613•587-1240 Fax 413.587.1272
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k . *LIG94T M TrQ.t34RUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
...........
SECTION 1!- SITE INFORMATION
This sect�o Ito b° omp'etedy office
1.1 Property Address: � e
I—� y a`✓.,SjA �A�`� .^°` JML�fi�'4he fz4•.
917 � S I rzec � JVIaP
a0 1M � �ItL a/06 06 0Zon D� #r ct
k k
Elm St District' GCB As rich r
SECTION 2 PROPERTY- -'OWNER! H F AUTHO:RIZED:AGENT
2.1 Owner of Record:
Name(Print) n Current Mailing Address:
I", C, � Telephone
Signature I.Y 1
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
S.ECTON..3.-ESTIMATED CONSTRUCTION COSTS`
Item Estimated Cost(Dollars) to be Official Use' 1nly
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)
5. Fire Protection
6. Total = (1 + 2 + 3 +4 + 5) Check Number
This Section'For Official Use Only
Bi�ildi'ng Pejmit-Number. Date Issued:
Skgnatu re:
1 Building Commissioner(Inspector of Buildings Date
T
219 BRMGF,St r BP-2004-0525
GIS#: COMMONWEALTH OF MASSACHUSETTS
l i�iii:131ock:25C-242 ' CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0525
Project# JS-2004-0742
Est.Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Homeowner as Contractor
Lot Size(sg. ft.): 7187.40 Owner: SMITH HELEN C
Zoning:URB Applicant: SMITH HELEN C
AT: 239 BRIDGE ST
Applicant Address: Phone: Insurance:
239 BRIDGE ST (413) 586-7894 ()
NORTHAMPTON MAO 1060 ISSUED ON.10130103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL WOOD 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 Sisnature•
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 10/30/03 0:00:00 Mo $25.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo
239 BRIDGE ST BP-2004-0525
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-242 CITY OF NORTHAMPTON
Lot: -001
Permit: Buiidina
Category BUILDING PERMIT
Permit# BP-2004-0525
Project# JS-2004-0742
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 7187.40 Owner: SMITH HELEN C
Zoning:URB Applicant. SM]THHFL N C
AT. 239 BRIDGE ST
Applicant Address: Phone: Insurance:
239 BRIDGE ST (413) 586-7V4-Q
NORTHAMPTONMA01060 ISSUED ON:10130103 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL WOOD 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:
1-7 3
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT N OF
ANY OF ITS RULES AND REGULATIONS.
pe
Certificate of Occu anc Si nature_:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 10/30/03 0:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo