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�* DEPARTMENT OF BUILDDNTG INSPECTIONS
INSPECTOR
'212 Main Street • Muiucipal 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 sup": i sor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,:a one oftwo fanuly- --'
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 r'.egulations. 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
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F e Cribf �rrrfljaiii}� oll - – —
��a3aArflnsrtta' - —
o OEPltA OP 5UILDr_,\,'G INSPECTION'S
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212 thin Strcct ' 'Municipal Duilding
Northampton, Mass. 010GO
WolUCIRIS COL TENSATION MSURANCE AI'II77A.�r1�'
I,
(licz.lis�J(�crmitttx) �
\with a plZrlcipai place of buSif]esSfreSldeIleC at: ----
(phone..
do hereby certify, under die.pa.ins and penalties of perjury, --.hat
(/am an employer providing the followint''%vorkces compcnsa:Jo, cove-MSC for my
etnployces working an this jib.
» yn /
(Insw—.n Conr v) Ir:-pirrrior.Dal_-)
O I am a sole proprietor, general contracior or homeow-Der(c cie one) and have hired
the coouacnprs listed below who hzve the foUo%viflQ worker's campersalion pokiest
(Name of Con':.'-cior) (InR!ranc- Comoii)-/Poiicr ?�iUIIl_C:I (r`:pIrzvuon Ditc)
(N:.mc of Coui=faclor) (Lias-ar7aac:. Ciomoan)•IPotim, `utmcrr) (L.—Dit lion Date)
(h1.me of Contracto,) (Laurance C.ompan}'/Poke)' Numb�.r) (Expim6on Datc)
(Namc of Coatractor) (Lasutanc_— CompaayfPolicy Numbzr) (E:cpitadoa Da1n) .
(arsa.� .{A:aocs!rhCC,if ncocu�•to 4tcv<3c inforr_�Mcc Pc,A!niag to.0
{ ) I am a Sole proprietor and Gave no one woridng for me-
( ) I am..a home owner performing all Lbe-work- myself.
NOTE:pl=_=be ew•xrc tb=t ]o hcc cc vm�to c=pIcy p�—soc3 co Lb�A=c= cr, r r rgzr work 0�2 a d•.c11^z of
Cot mote thm Lh=---a to whxh the bom owo.r read-.or cc th,p-ou ax C-=:-UY ar1:6=-�i to be
c�playc�uar''c thew S ctpc.._LOn Ar-(GU.1 SZs 1(5)}.:�PG=6aa by a homoowva fc e bc=-__or permit rz:y c.-idco-the
IeS. et-2-of m e=ployor under dto We kc e,C.oa�o.n Ad_
a
[undcsir..ed that a Copy of e15i.mScm m m..y ba ford d to the pcqutmcce of Iada+. W A.&&&061—of t+�v�oce
eoYa�c t'c'ilcztioa and tltei L•iltac to soauc Lovera�e tmdes socZioo 13A of 1.tdL 151 tin lu-d to the i�itioa of oiminal penillia
000si:stg of a rise of up to S 1 500.00 andfor iaaisonrad o(up to Coe ycr Lod ri%il P=A_tja io 6c form of a Stop W oric Order"a
fim of S 100.00 a d_y Lvda-A tnc
For dcp.rtrti.�u,o only
t`I Pcrmtt Nujmbcr
Lot"I
Sir, aLurc of I_ic=Scc/pccrniucc/ e
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ) Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Zo
Signature Telephone
4r�-- JI-
R ° �3_ x y
Not Applicable ❑
4 C--
Company Name Registration Num er —`
0 J/
Address Expiration Date
Telephone_yY y%6
SECTION 10-WORKERS'COMPENSATION INSURANCE:AFFIDAVt.T(M.G:L.c:1'S2,;§25C(6}}
Workers Compensation Insurance affida t must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the build' g 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 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 ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofin
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding Other[0]
Brief Description of Proposed n)S f79 ' r 14/N(,. nl ���G �•
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
�:re,.,,�' �°- "° =. s=4,ko-;'r5
fa (f M 4 'bd§e K r .c d ><a o eexEStl�c fio s. lct eol rte et ie 0 IBM
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 7a-OWNER AUTHORIZATION TO.BECOMPLETED ;WHEN
;OWNERS AGENTbM kTRAETOR APPLIES''FOR BUIGDtNG PERMIT
lj ,EJ t�
L54 C) Q as Owner of the subject
property �--
hereby auth rize
to act o behalf,in all matters relative to wor uthorized J5y this building permit application.
,-
Si nature of r Date
as OwnerfAuthorized
Agent hereby declare that the statements and information oA 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
Sign tureofA /Agent Date
{
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
i
Lot Size ! �
Frontage —
Sctbacks Front i
Side L:! R L R:- 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?
N0 0 DON'T KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
IF YES: enter Book Page, and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Q Date Issued
C. Do any signs exist on the property? YES 0 NO
s
IF YES, describe size, type and"location: I
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q P, NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
e
y
City of Nortf ampton t
6 -
Building Department
212 Main Street se
�. Room 100
Northampton; MA 01060 e
�P
hj 413-587;-1240 Fax 413-587-1272
�'r ! J /_ '�til2F .peC - �.c' .:`"'y'e�" g"3:vg z•- iYC 'a ,+, ro}ij2,.
APPLICATION TO CON irRUCT ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
.5Ei I. It-1 -SITE INFORMATION
1.1 Property Address: Thts section to be completed bxof tfi
'5— -�3
0/ '� � �Q , �°' Zone Overlay DEStrrct
Elm Sf Distrrcf CBMilt trfct
SECTION 2-PROPERTY OWN ERSHIPIAUTHORIZED AGENT
2,1 Owner of Record:
ZF-ba .>se 7'� Cleo t/I) X i d
Name Current ailin ddress:
Telephone
ure
2.2 Au ized Aoent:
Name(Print) Current M iling Ad ress
Signature Telephone
SECTION 3-ESTIMATED-CONSTRUCTION COSTS
Item • Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building tyc (a)Building Permit Fee
1 0O
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) /02 d a Check Number
This Section For Official'Use Only
-
Building.Permit Number :Date,Issued:
Signature: r
Building Commissioner/Inspector of Buildings- Date
a a a
$ a t
485 BRIDGE RD BP-2005-0822
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17B-025 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0822
Project# JS-2005-1139
Est.Cost: $1200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq.ft.): 21736.44 Owner: CROVO ELIZABETH A
Zoning URB Applicant: B & R Siding
AT. 485 BRIDGE RD
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:312105 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL SIDING ON GARAGE
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 Occupant Signature:
FeeType• Date Paid: Amount:
Building 3/2/05 0:00:00 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo