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DEPARTMENT OF BUILDDtIG INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building '
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to
act as ris/her construction sup,. ,P or. 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 backfll),
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
de
I, understand the above.
(Home owner/resid pt'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
i
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A E -qIa3awcharcttn-
w DEPART MEI-IT OP BUILDD\10 INSPEC71OI.S
212 Main Strcct Municipal Budding
! Northampton, Mass. 01060
I
wOIUCEIZ'S COMTENSATTON GISU ZA-NCE A17FD)ei.N'I-j'
1 I, -- ----- -- (litznsxllxnn)ttcc) --- -- - ----------. -. .....--- ---
v4th a prulcipal place of businessfresidenc.e at: ---
(phone')
^ (Scrc_..t1ci ty/natcl i P)
do hereby certify, under tlic.pa_ins and Penalties of peflury, h:t
1 -
( ) I am an employer providing the following!workcr's cotnocnsaoon cove sc for lay
emplovecs worming on tlus}ob.
(UISU--n=COQ?✓2ZV) (POISCI NU-Mb-CT) -- (r:-pirat orr Da_=)
I
( ) I am a sole proprietor, general conn-actor or homeow'Der (ciu c;e one) and Lave hued
the contractors lister+ below vto leave the follolving worker's compnsaaon pokieS:
(Nam-, Of CO2- =Icl0") On urancc CoInpan)-i-Pr lc-, !gLUn=C-) (-Ixpinjucn D.-Itc)
- (Namc of Coamcior) CLPsurancc.ComoanwPoUcy \t Herr) (E»ir.:tion DattC)
I
(N:the 01 Coacmcto;) (Iosulaac:Compan)•fpol.cy Date)
(Namc of Contractor) (LOSUr3IIc-c Company/Policy Num.b-`r) (Expi-,6oa Dau).
. faIISC3 ad'!r�ocal t'�cC,if nc�zr.-t•w a�cvC;iaform,�oa pczta'�to.11 cua-_r..n;�) -
O I am'a sole proprietor and have no one workiog for me.
I am.a home owner performing all the Nvork myself.
' NOTE.pl=se be cw-4re ti- +tJo wtw employ p,=-.<r= D cU cr a.o c rcpQQ••-oric oo.d%,'U-g of
ant—tbeo tbrev—, is--bieh ttx hotnoo we rands a oa the out Cc=--Uy a>erdznS is be
aitplaycs u--the..•o;i;c{7 rcz- -.,:oa A,=(GLIt 5Z=1(5)),mppUca.ioa by a bomco-ma fct-bcs_of P==Lh r=y cNid=oc trc
lcss n•..,.of=a ployer under din Wocir, -L Compom.lioa A.&-
i
i
I uadczzwd ds+a a o vy orthi.mrcaum may be foa�.e.rdad to tbo Dcgarcmr�i of loda+sriJ Aaadcdo'011ioo of tdu—roc the
coverasc veireaioa and th_t L-iltac to r-onrrc)overact undc section 23 A of h(GL 152 m Ied to the i^posaioa of eri.;ZA P-16-
of a fine orup to SI}00-00 and,t izIIprisoam� of up Lao=yc r cad aNi1 pens a=in tSc form Ora Slop Wort;Ordrs and a
f=of S 100.00 a day apiaR me
i r/ For dca.rtm'�u.c Doty -
I �� C7SIIJt t`lUIDtX:S n _
.I �,.[•,px Lot A.
Vtauurr of Lic=tsccJ crrn ucc e -S
SECTION.8-CONSTRUCTION SERVICES "I
8.1 Licensed Construction Supervisor; Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
A- re Not Applicable ❑
Company Name Registration Number ---
Address Expiration Date
Telephone
SECTION 10 WORKERS'-COMPENSATION INSURANCE AFFIDAVIT-(M G:L.6.', 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...... ❑
” a
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 considgred a homeowner.
Such"homeowner"shall submit to the Building Official,on a form acceptable to the Building Official,that he/she shalt 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 respo sibility for compliance with the State Building Code,City of
Northampton Ordinances,State d Local aws d Sta of Massachus s neral Laws Annotated.
omeowner Si nature � ter,
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SECTION 5-DESCRIPTION-OF PROPOSED WORK(check-all-applicable
New House ❑ Addition ❑:: Replacement Windows Alterations) Roofing
Or Doors F-1
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C7 Siding[0] Other[[I]
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
o f Nev rbFis a dd'oo .c[c1t1eMd ei�tr9.*6i a c o p e he f�oy :
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
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
SECTION Ta-`OWNER AUTHORIZATION TO BE COMPLETED.WHEW
OWNERS AGENT OR'CONTRACTOR;:APPLIES:FOk,BUII DIN6PERMIT-
I, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building 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.
Print Na
ti.
476
Signature of Owner/Agent Date
~
^ '
' .
--
Section 4. ZONING All Informatibn Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This colurnn to be filled in by
Building Department
Lot Size
Setbacks Front
Rear
Building Height
Bldg. Square Footage 0/.
Open Space Footage %
(Lot area minus bldg&paved
of Parking Spaces
(volume&Location)
A. Hus a Special Perm it/Varunue/Findi ever been issued for/on the site?
No 0 DON7 KNOW x~~^ YES 0 �
IF YES, date issued
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONTKNOW 0 YES
IF YES: enter Book Page, and/or Douument#
-
�� �� ��
8. Does�hesi�ocontainubruuk' budyofwmtaror�a�|un�� N� v�� DON7KNOUV v�� YES «+�
IF YES, has a permit been or need tn be obtained from the Conservation Commission?
^
Needs tmbeobta/omd x�� Obtained �~� Date
v�� �~� ' �
C. Do any signs exist on the pruperty �� ��� YES v�� NO «��
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YE3 �~� NO 0
IF YES, describe size, type and location:
E Will the construction activity disturb grading,excavation,m filling)over 1acre or isdpart ofo common plan
thawN|di$urbove,1aore? YES K ) NO K
� ~�,)
~~�
|F YES,then o Northampton Storm Water Management Permit from the DPW isrequired.
t .y
Wit.-fNbrtf ampton P
wilding Department
212 Main Street
Room 100 aka `
APR 2 1 24arthampton; MA 01060
phone 413-587-12410 Fax 413-587-1272tg a �
}
APPLICATION TO CONSTRUCT,-AL�ER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION.1.-SITE INFORMATION
This section to be campieted b�f nce
1. Property A dre�� � � R �
Nfap Lot Unit
b �Ozo�ae E7�erfaDbsfc�ct
k ru
�EI�mS�D�stnct s' � " �CBDi53Pc� s
SECTION 2-PROPERTY OWNERSH1PfAUTHORIZED AGENT`.
2.1 Owner of Record:
Allalf 12 F ?03
Name Pri ) Current Mailing Address:
,. �— =—
01 Telephone A(4
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3'.-,ESTIMATED'CONSTRUCTION COSTS
Item - E timated Cost(Dollars)to be Official Use Only
om leted by ermit applicant
1. Building �D B (a)Building Permit Fee
c
2. Electrical °(b}Estimated Total Cost
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
Date
Building Permit Number issued:
Signature:
Building..Commissioner/Inspector of Buildings-- Date
R
BP-2005-1015
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Buildina
Category BUILDING PERMIT
Permit# BP-2005-1015
Project# IS-2005-1395
Est.Cost: $2500.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 26658.72 Owner: SCHMIDT CHARLES
Zoning: SR Applicant. SCHMIDT CHARLES
AT. 685 RYAN RD
Applicant Address: Phone: Insurance:
685 RYAN RD
FLORENCEMA01062 ISSUED ON:4121105 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 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: Date Paid: Amount:
Building 4/21/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo