17B-016 (5) O¢'SHAa1P�O
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DEPARTMENT OF BUILDINTG INSPECTIONS
INSPECTOR '212 Main Street • Municipal 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 l,is/her construction sups.:-,•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 fami� -
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 rouzh buildinz 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
1� I understand the above.
(Home ow /resident's signature'7equesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date '3c_s 1
Address of work
location y\ �z
Rfi ti� (rill of {n� fljalil}�fo�l - — =
A_ E _ _
�ic3ai<cllrtscfla'
a DEPARTMEIrT OF DUILDr)\G INSPECTIOI.'S
j 212 Alain Strcet ' Afunicipal Buildinp.
Northampton, Mass. 01060
WOR.Ia-R'S COKPENSA'nON MSUTZA�CE AI M, 11�
0i ccnsxJpertnj ttcC)
%I..rit-b a principal plac. of businessfresidence at: -- --
(;hone.')
(sv�t/ci tylaalclri P)
do hereby certify, under the.pzi Is and penalties of perJury, :hat
( ) I am an employer providing die following %vorl:cr's cotnocasado, covemle for Iny
etln})iovices wortang on Lin'S jib:
OMSU-ran=Coei m) (Pclic-:Numbccr) --- :oirvor, Dam)
O I am a sole proprietor, general contractor or homeowner (c c:e one) znd have hired
the contractors fisted below wbo hive the follotvinQ workers comoep—tiaon pokles:
(LIcMC of CO„^Ci0r) (It1SUr1t1t Company/ni r,6c }��uII1��:) �C�l:d ^?Datc)
- (N MC of Coaracior) onsaranc;. Comoaay/polio; (Ex o LM.tion D`r-)
(Name of Coa=C10-) Gasuranc; C0mT=)-1PoG-q- Nusij) (Expira600 Datc)
(Name of Contractor) (Insurance ComoaryRoUcy Nu.mbb`r) (Etpiraiioo Datc).
(aaxb_d1�cGl z'ua,ifaca-.0--v =focciajoa PcJajains to CU oocn--r_o:'�)
O I am a sore proprietor and have no one work-ing for me.
I am.a home owner perforr=c, all Lbe work myself.
NOTE:plese lx nwuc tfi•• +t Ic 6cmcrn+vcn wtbo a ploy Pe-%-O=to do¢. �-.c,n c mpaa work ca.d..�� -F or
aot Moce th-a tr--v:unrr in«$ic h the bornoownc rr�dc3 or oo the aoua6 zppurtcn rj�theee,we C=) .Xy oc--d.-nd to be
eirploycs ual a tbc--k.e—z C=P=-*'m A=(GUI SZ=1(5)).ar^PIiaDOO try a boa=%-=far c G�_or pamit r>_y e idmoc the
Icp.l Hasa of ea==Ployoc uodcr dao Woctca![C.oa�o Ad.
I uo4cmr-od dLd a OOVY of this c=z�=,ty bo for--id ro ti,C� of jo,s J Ac &Cly Offioa of Iru+c•ooe foc the
oove rciLesioa Had th1 L-il=-C to sczrrc)CovCMCI=UD&--:oeiioa 23A of h(GL 152 era I=d to the i=Positioa ofaimi-d PC-.W-
eoaii..itt$of a fine orup to 51 S00.00 andfcc irz�rz orup to ooc y-=ead a,it p..kl.is t5c form of a Stop Work Orde and a
fl=o(S100.00 1 rLy•wit me
,. For
Permit Number
\ Lot
"U` Siinatum or crrn;ucc J
SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9...Re" sere 'Ifome>lm eoveirier`t Doiitractar " u
--�-- y�"� .__ � Not Applicable ❑
Company Name Registration um er -- --
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE A" AVIT(M.O.L.c.t32;§25G(6jj
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-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 Zonin and State of Massachusetts General Laws Annotated.
/Homeowner Signature
r
'i
r
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all amlicable
New House Addition Replacement Windows Alterations) ❑ Roofing
Or Doors C]
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding Other[E3]
B ' escription of Proposedy�� �� ^
or k:
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa. lf��fi"ew�t�o�se=-a:nd.circ�cL#iO�ri� sfi�"'bausin �:car� `fete�the�fo�fo�ai�i`:
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.
1. 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, 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 Name
It
nature of Omq e Agent Date
~
Section 4. ZONING Al I Informatio'n Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
nis column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height r-77=
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume,&Location)
A. Has ! Perm�/Vorance/Fndi ever been �suodfor/on the s�e?
' x~� �~� x,� �
N0 �� D�7K�� �� �� ��
IF YES, date issued:,
IF YES: Was the permit recorded ut the Registry nfDeeds?
NO �_��
� DON'T KNOW 0 '^^
IF YES: enter Book Page and/or Document#:
B. Does the site contain u brook, body uf water orwetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has o permit been nr need to be obtained from the Conservation Commission?
`
Needs tobeobta(ned *~� Obtained x�� Date
x_� v_� ' '
C. Do any signs exist on the property �� ��� YES �~� NO �~/
IF YES, describe size, type and |000dnn:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb grading or filling)over 1 acre oris it part ufo common plan
thowiUdisturbnvor1acre? YES K ) NO ~—~K )
~~^ >
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
`
City of Nortf ampton Pe '� °�
Building DepartmentrD
212 Main Street SevrrerSe t y ila6tlity a§
Room 100 etGya�a�btYtt �' �
Northampton; MA 01060 Sets 3tr ct rai PF s t �W1'w M
kmO
phone 413-587-1240 Fax 413-587-1272 PtotSlPfans N # ,
OthecSpecl�r'�rM• ' lY%z,r'' r��` m-��$e?t a- ` °'
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION.1-SITE INFORMATION
1.1 Property Address: This.section to be completed by office
Map Le Untt
Overlay Distract
Elan St Distract ' C8 D1strict
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
C
Name(Print) Current Mailing Address: —k —2 c�
Telephone
Signature `
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
com leted by ermit applicant
Building (a)Building Permit Fee
2. Electrical U v v (b)Estimated Total Cost of
Construction from B
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.Onl
Date
Building Permit Number. Issued:
Signature:
Building Commissionedtnspector of Buildings Date
A
419 BRIDGE RD BP-2005-0378
GIs#: COMMONWEALTH OF MASSACHUSETTS
MV.W,:ock: 17B-016 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-2005-0378
Project# JS-2005-0500
Est. Cost: $1000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 43560.00 Owner: SINGH JAGDISH&BALBIR SINGH
Zoning.URB Applicant: SINGH JAGDISH & BALBIR SINGH
AT. 419 BRIDGE RD
Applicant Address: Phone: Insurance:
419 BRIDGE RD
FLORENCEMA01062 ISSUED ON.9130104 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VINYL SIDING
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: Receipt No: Date Paid: Check No: Amount:
Building 9/30/04 0:00:00 559 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo