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DEPARTMENT OF BUILDITIG INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building S
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as } is/her construction sup( :,, 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
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
T
f 0L� `SlfyT of �;\ilutijcllliptoll
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^� m Iml,"U Ot' %UILDD1 G INSPECTIONS
212 Alain Street ' Municipal Building
hrorthamhton, Mass. 01060
WORKERS COMPENSATION I SURANCE A.FMANr1.T
(11�nS"_:��CrrinliiC.^_)
�vlth a principal place of busiresslresidenc
.1 7v
do hereby Cer—Lify! U'7;Ic1 L11C l):::i1S ;Inc pcnl l(ICS 01
tam Lill ermployei- providing the. i011o villa v,ort:Cr`S Compensat.70I1
eltlployces worldrig on this job:
-
-
l j I am a cote proasietor, zentra Gin c of honlcotvzef (c cle one) and have hired
t.tie contmctafs listed beio vr ;,t7o the `01G': :v ' %Ofners GJ%pen Orl "01C`.cS:
(I`:ame of Contactor (Ins,I-�nc:. Comc::a-;:'Pc!ic; Nulntvr i�':: .�.�cn Datc)
(Name of Contracts;) -- (Tasur-.nc-- Cor r:v(Pe!ic; Nt!Ii1b--r) (I ;~tioa Date)
(Name of Contractor I.II1S'.I7mc (_.,w}?uvi-Po!iC' I`iumber) 'tit c-7- Date)
(Name of Contractor) jasumnc:. Comr Y/PoLier Numl`u)
(sridi:.d-±iticcil cE:-Q is r:ox-•.^::n•�-....:.-:::C�r::u[ic;:-__:c�..:.,� - �i;o:�::_:�<::•-)
i
l_ ) 1 2LIT1 tt SOIL l)1 Oprif:0i 2IIQ h ?vC i10 OI!'C :1,; f01 .11e.
� �) � r!iIl �? 1101710 0�'JI1C:" GCi?C`In1Il al i•'i., 't'.. ..; ii."'r��.lf.
NOTE.:plCasc to atva:c thst•_:)c FKc 7,40:r;r--r:: -n r pl ,'lr U) ct:ri air d«cliia
not uxte t!t_n Liu-cc uui l i t<L et he t. .ti�.:.r rc: s 4c a; •_.-,:i z r., c: r1 Lhcdc c r{
CZ1:ploya3 u.�r the%o'Wk --ca z :e!i n F (<3i.!52� 1(51;,a,:;:catia;S a hnmcou�r:`er a Larix C�P:Tr:i::: _ ...'.rye
legal ctatuc of an a=plo)w unur 4`.o Wcvt;cli
I undc--xAx d thi,a cmy of ths, ctatci:r_•cuy E.fa-,U:iod to t!n C Iz�utr,cl Anzd�tj<%tr�°oC::='"r T_n for i!x
cove vaificmtioo rnd that L durc to uC cowrg^ur3::ctii x!25A of?,f GL.152 can Ic-d to the imposition of r .1 MIS"*:=
existing of a fur of up to s 1.S�.CuJ a:'.'Y i�:�ri x Zti:_of::p to on*; e:.1 civil xsult u in;c r-rttn of a S!r,,
frzr oCSI00.0U e diy ir:.in:l m..
r ar cSq%+:un^sfsl u.c cril y i
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S�CTN 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Nat Applieeble--E�—
Name of License Holder : C' G t� t rv, of°o
�✓- y License Number
Wb a y-l ols--
Address Expiration Date
_ V
Signature Telephone
g om m'nroyernerit Contractor , � � r ffli Not Applicable ❑
G.C-; �v -1 er -! ant C—C15
Company ame Registration Number
Address Expiration Date
W 0 f 01-? Telephone
SECTION 10 WORKERS' COMPENSATION Ip SU NCE"AFFIDAVIT(K,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....... b/. No...... ❑
IN
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 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 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
r ,�+� < T
.... ���
SEC:T,♦Qf , S T R�PTF0IUOFPROPOSED�WORK(check all Fapahca�le� w ""�'`�
INA
�::•r:�;��,, fi°x� �.�,':?"�,�"'ss..�rte. ..,� .„a ,..a _ ..... '; , :, „3 n � ,. ,e�u. �� - ��{
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 L—No A ding new b Broom Yes _L,` No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 •Sheet 0
6a
Mew, se a id or'�"" .d:dition to existing h uo sing c-o p:efe�ie;fof=low:ing:
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
SECT�OT�I �OER AIJHQRIZATION TO:BE COMPLETED WHEN
OWffSA ETOCONTRACTORgPPL'lE5°170 R BUILDING PERMIT
I, �, (��r as Owner of the subject property
hereby authorize CA, `-0, L _ to act. or,
my behalf, in all matters relative to work authorized b this building permit application.
a..6
Si ature of Owner Da e
I, S TC4 G 'S G` e as Owner/.Authorized Agent
hereby declare that the statemenY, and informatiGYon the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Nam
to
Date
Signature of Owner Agen
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 l/ YES
rte '
sue y�.,.�+�rM .
sr!: ,,� G� /h
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 Lr
IF YES, describe size, type and location:
D. Are t ere any proposed changes to or additions of signs intended for the property ?YES _
No
IF-YES, describe size, type and location:
City of Northampton t
��. I ing Department
2 Main Street -
��1 ` Room 100
No>r, pton, MA 01060e
n,r„
l `' ' t�n '14`13 j5 7-1240 Fax 413.587-1272 P � .
�f.
Al CA�trSGfptiNS,_ TjLICT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This sectio*i�to boom eted�by.�office;`�"m "`
1.1 Property Address:
s
Maps ,Lo, cast
o Zone Ou aria
K �
un y ��y.
Elm St Distr ct � CBDisrict
SECTION 2 -'PROPERTY OWN ERSHIP/AUTHORI.ZED AGENT
2.1 Owner of Record:
Name(Print) 'urreA fling Address:
�1 �Y1 G. 01 0
ephon
ig ature
2.2 Authorized Agent:
Name(Print) Mailing Address:
Signature Telephone
SECTION.3:- ES.TI'MATED Ot45TRUCTION.COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
-
1. Building D (a) Building Permit Fee
2. Electrical (b) -stimated Total Cost of ,I'
Construction.from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5) /o 0 Check Number _
This Section For Official Use Only
Buildi,n.g Permit Number: ;- Date ssued; _�
Signature:
L Building Commissioner/inspector of Buildings Date
T
BP-2004-0443
GIS#: COMMONWEALTH OF MASSACHUSETTS
imallaw"e"W, CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2004-0443
Project# JS-2004-0641
Est. Cost: $7100.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STACY BUILDERS & CONTRACTOR 115352
Lot Size(sq. ft.): 16378.56 Owner: HEYMAN JON B&KAREN S ROWE
Zoning:URB Applicant: STACY BUILDERS & CONTRACTOR
AT. 13 OAK ST
Applicant Address: Phone: Insurance:
P O BOX 217 (413) 665-6970
WHATELYMA01093 ISSUED ON:10120103 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP, PLY & SHINGLE HOUSE/GARAGE 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:
FeeT_ype: Receipt No: Date Paid: Check No: Amount:
Building 10/20/03 0:00:00 MO $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo