17B-011 1
LI y of Xart4autpton
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DEPARTMENT OF BUILDI7`G INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building '
Northwnpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/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
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DEPARTMENIT OP BUILDING INSPECTIONS
I
212 Maio Strcet Municipal Duilding
Northampton, Mass. 01060
%V0F C:R'S COPYPENSAU70N L't'SURA-N CT- AFFM,,-iV1T
1
(I;ccnsxJpermiatcc)
wlLh a plu,-tcipal place of business/residence at:
(sit/c�rlhuJ.c/rip)
do hereby certify, under dic.p?-ins and penalties of penury,, :hat
( ) I am ao employer providing the followine �vorkcr's comocrisZtio, cove zSc for Iny
etuployces worbng on uiis job:
(Lwur`;�=Compam,) (Pclic; t:u-ml�cr) (E;-pinion D?i-- "
( ) I am a sole proprietor, general contractor or homeowner (ci cie one) and Lave hired
the coauactors b e+ below wbo have the fotlo ing workers comoensa 'on policies:
(NHale of C0 n- ttmci0r) (IRRlranc: Coinpa ryI?o6c-i (EX:w-au0n Daac)
(Name of Cooaraaor) (InswJanc;. Compaq-iPol.ic-,, Numcrr) (LkDir:tion Date)
(Name of Cotl>raeaor) (Insuranc:. Compzc)-/Poliep Numbu) (ExDi-zuoo Date)
,I
(Name of Coa✓7aaor) (Insuraacc Comczay/Pot cy Numb r) tEtpir�tion Datt).
(ea�r�:dai�ocsl�xd.if ncocaa�-w mcud_inf«tia,��oa pcz�n�.ain�w,.0 ovs-rn:-a) - .
{ ) I am a sole proprietor and have no one worfdng for me.
(xI am.a home owner performing a!1 the .Mork myself:
NOTE:plcsc be curve tti,.-t-JO bem=D-acn-bo employ peso=w di c.c -• cis c,uo r rcpao wocz on.d,,cll_y of
orx mote the n ttlo �is aatych the bomoowocr raid=oc oa the pvuix4�zppsrtc= =tb�-cn L-c ooc oeer'dcrctii w t+c
e�iployc-� �e the..ui d:Derr ---,:m Aa{Gt 132s=1(S)),,zPPaicz.6oa by a homwQac fer:!ice_«permit r= c,-idmoc the
Icp1 nom lu of cm o=:PdOyor uodar duo Wocko',coa>pomaiioa Act
[uada-rtuad dsu a oopy Of abia c 1 may ba lore ncded to tba Dopartmro¢of tOC6asticl Ac�dc=1 Offioo or t�+raOOo for tba
eoverise v=ZC31iao and Oi--t L-.mm to secure LO%-` a ttOdcr S-OC i00 25A of MOL 152 ern Icd w the=Poliiion Of eiminal Pets W=
eoasi=a=%of a fiat crup to S 1 Soo.00 andror i npri of up to a=yc3r end aril pcmatia is tx foray of a Stop WorE Ord-and a
fim o(S100.00 1 day 1�X=me
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SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
in Up,
c a x. rTl fln[3w Not Applicable .❑
9: ?e rsteredHorrr emen
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE x1FFIDAVIT(M.G.L c.1'52,,§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-m, 1 5111=61 u
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 o al Zon' d State of Massachusetts General Laws Annotated. - -
Homeowner Si nature .
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SECTION 5-:DESCRIPTION OF'PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding[0] Other[170
Brief Description of Proposed
Work: /dys��i� '�� . �►/ �<'�L � / t.� .
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.�fi�few'�houseatYd�or add��or�to'�xrs�ina hous>ina�'-:eamptete��e%�ow�ng:
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-OWNERAUTHORIZATION•-TO BE COMPLETED•WHEN
OWNERS AGENT OR'CONTRACTOR<APPLIES>.FOR.E.UILDING:PERMIT-
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
1 ,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
Signature of Owner/Agent Date
� .
Section 4. ZONING Ali 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
Frontage
Setbacks Front
Rear L
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus b1di;&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Vahonce/Fi riding ever been issued for/on the site?
NO 0 DONTKNOVV 0 YES 0
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
'
NO 0
IF YES: enter Book and/or Document#:
B. Does the site contain o brook, body of water cvwetlands? NO 0 0]N7KNOV 0 YES x~�
IF YES, has permit been or need to bo obtained from the Conservation Commission?
Needs tobaobtained 0 Obtained 0 Date Issued.
C. Du any signs exist nn the property? YES 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES x,� NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,nr filling)over 1 acre nrioitpart oiu common plan
that will disturb over 1 acre? YES �� NO ����\
��
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
� J
City of Northampton
Building Department 6 �
212 Main Street "
Room 100 r i4 � ��
Northampton, MA 01060 _
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
�_ �( This section to be complefed by�ffice
1.1 Property Address: t t
AUG 2 1 20a�
L®ice# l� t7l Z OverFayOrstk7
Dl >�
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SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(P�'i�yt}--� � Current Mailing Address:
-- / 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
1. Building (a}Building"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) F Check Number 3j6? 1
This Section For official Use Only
Building Permit Number. Date `"
.Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
s
BP-2007-0205
Mr GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2007-0205
Project# JS-2007-000309
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Homeowner as Contractor
Lot Size(sq.ft.): 19994.04 Owner: MOHAN EAMON F&ANNE-MARIE
Zoning: RR Applicant: MOHAN EAMON F & ANNE-MARIE
AT. 400 BRIDGE RD
Applicant Address: Phone: Insurance:
400 BRIDGE RD (413) 585-0082 O
FLORENCEMA01062 ISSUED ON:812212006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL PELLET STOVE
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 Si nature:
FeeType• Date Paid: Amount:
Building 8/22/2006 0:00:00 $25.00367
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
400 BRIDGE RD BP-2007-0205
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17B-011 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2007-0205
Project# JS-2007-000309
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 19994.04 Owner: MOHAN EAMON F&ANNE-MARIE
Zoning:RR Applicant: MOHAN EAMON F & ANNE-MARIE
AT-- -41.10 S- OGE- n
Applicant Address: Phone: Insurance:
400 BRIDGE RD (413) 585-00821)
FLORENCEMA01062 ISSUED ON:812212006 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL PELLET STOVE
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:0 k -Q G
THIS PERMIT MAY BE REVOKED BY THE CI Y OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
C Certlfica t of OCC n
Si nature• �•�
FeeType: Date Paid: Amount
Building 8/22/2006 0:00:00 $25.00367
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo