28-012 Q.'tK'�'ypT
O O
of Nart4ainptan
�IIR3DRCh1[SttYB a
DEPARTMENT OF BUILDIJ\TG INSPECTIONS /-
INSPECTOR 212 Main Street • Municipal Building '>o
1y S. y
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/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 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
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
O4-(t�lJ-7 p�O .
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DEPARTMENT OP BWLDD�G 1NSPECrIot:S —
212 Main Strcct Municipal Building
Northampton, Mass. 01060
',N'O IUCC IZ'S C O NtP ENS An 0 N M S URAN CF- Al, , A VIT
(li ccluxJperm�ttcc)
t1,1itb a principal place of business/residence at:
(ph0 0 e:=') �1 %J 3
(str�t/ci ty/slaLcf��-
do hereby certify, under the pa-ins LDd penalties of pef7ury,, =hal
I_ -
( )' I am an employer providing die followint, workers comoc isado, coverage for Iny
e1uployces Nvor_ong on dlis job:
(La5urncc Comps,-) (Policy Nu.mbcr) -- (r:piratior DzL}
O I am a sole proprietor, general contractor or homeowner (c c:e one) and have hired
the consact prs listed below wbo hive the '0Llo ing workees compen_tanon pol}cles:
(i+1IDC 0- Contnc-,or) (ln-urancc Coinoa i)- obci D liC)
i
(N me of Coo>?aezor) (1nslrane;, Comoanvipobc NUM cr) (–Expirtion Date)
i
(Name of Connano,) (I.nsurance ComT=y/PoUq- Number)— -Me Date)
(Name of Coaaacior) (Insurance Compaay/PoLcy Numb-,ir) �T-xpirdtioa Datc).
(atx.a,3t uddibocal bcG.ifacoau�•to c,c!udc uafor�zoo pcxta,in.ias to.11 ate--,..c.o:�) - .
(V,I am a sole proprietor and bave no one worming for me.
( ) I a.m,a home owner performing all Lbe work myself.
NOTE:pl=sc lx eortlr tt..v1 Je bemcov am to CZ=PIQy P--Iolm w do c• 7 c=--,ec,00 c rcPzIr work oa a d-J--Z of
ont moct tb a L`lcc,�i�is u3ic�Fbc homootwc rtxida a oa the _,z,�p utto r3 tbecn WT ooc C._,.r_12y oca:d-od to lac
ct tploycs ud,dc Cbc,.�i Zim A=(GL152=I(5)�=pp1id3600 by a boa=-=fcr c lice a pamih rs=y c.idcaoc the
IcgaJ c=i of en-=Ployoc uador d,o Workers Coo�ioo Act
I uadcr=t d dud x oopy of this co U® oaay be for,,,ded to dbe Doponmcnd of j d-, ricr Ac d-&Off oo of laa—for the
covcrx c vc'ifatioo And a--'f:..iltzc to -==fovcrasc undo section 25A of l.iGL 152 c3a lad to the i=p=ition of aimiaal pcniW=
e0m,sLX6 of a fins of tP to S 1500.00 end<or oCup to ooc ye e.od CS\'il pcmt-,ia is the form o(.Stop Work Order end a
fim of S I oo.w.d_y�Pj=W
permit Ntuntxr
C) Lot
srrnaw'-A.f Lic=scclpermiucc ice J
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable D
Name of License Holder: \"S n, 0- ) L b
.mss License Number
rnk�Ah 1, " 0 9
Address Expiration Date
SID - D L ca _
SiThat—urd Telephone
J 2egrsierec .l onie maraaement-ontlacto> � ;K,R y Not Applicable .❑
Company Name Registration Number
Address Expiration Date
Telephone _
�-n
SECTION 1'0-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...... ❑
>r e Q 1 - .
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-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 be/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 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House F-] Addition [] Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [❑] Decks [M Siding[❑] Other[❑]
Brief Ref cription of Propose
Work: o t f VC,) 1n A •I,VI 0°�
Alteration of existing bedroom_ Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ioris'e�and w aaditivt� a GPJ pe e asa`�f ew. �nrma:
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. Masscheck Energy Compliance form attached?
h. Type of construction
L 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"AGENT OR,CONTRACTOR.APPLIES.FOR"BUILDING PERMIT
I,
qN as Owner of the subject
property NI
1
hereby authorize In9 --V'-VV
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature df Owner Date
as Owner/Authorized
Agent hereby-declare that the statements an 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.fp
k !1 `1 " 't.
Print'1 ame v
2--) *<�;=t -oq — JC
Signatu a of wner/Agent Date
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Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm b/Vahanco/Findi ng ever been issued for/on the site?
��
NO �~��� DO07KNOVV \_� YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry ofDeeds? '
��
NO �� DON'T KNOW 0 YES
IF YES: enter Book Page, and/or Document#\ �
'
B. Does the site contain a brook, body of water urwetlands? NO �_�x~~� DON7KNOVV x+~� YES \~�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �� Obtained �� �� |���
�^~� k_v ' .
C. Do any signs exist on the pvoparty �� ��V 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 �-v NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,n,filling)over 1 acre oris it part mfo common plan
that will disturb over 1 ucnuY YES [ D NO ���)
��
|F YES,then o Northampton Storm Water Management Permit from the DPW in required.
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„� �� �� ��De artmerat�tseurnty
�x
City of Northampton
Building Department
212 Main Street
Room 100er eii tlabr � � ,
Northampton, MA 01060
r
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
t ,7
SECTION 1 -SITE INFORMATION
N #� Fttis"5e tw�t ,e cPM feted by office
1.1 Property Address: r � � •.* �`4r.”.
n
s
Zone Ovexlay'Dxstrtct
r s
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print)/ Current Mailing Addr/,�
- Ly
I/ �/ Telephone
Signature,
2.2 Authorized Agent:
XW L lee J
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)Bullding: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
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
4
1 'k BP-2008-0132
GIS #: COMMONWEALTH OF MASSACHUSETTS
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-2008-0'132
Project# JS-2008-OCIO204
Est.Cost: $4785.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 152172
Lot Size(sq. ft.): 34891.56 Owner: BLAKESLY BERNARD A&GAIL A
Zoning: RR Applicant: BOB THIBODO ROOFING & SIDING
AT. 272 SYLVESTER RD
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527-7663-0
NORTHAMPTONMAO1061 ISSUED ON.81712007 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE MAIN HOUSE ROOF &
PORCH
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: Date Paid: Amount:
Building 8/7/2007 0:00:00 $25.003069
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo