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K" DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street * Municipal Building
Norti mnplon, 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 supc!-visor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or hvo 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 backfrll),
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
1, 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
Crzfu O �c7z ili�tltt}ttL�tl _ _ —
g B ��:sanchuartta
m DEPARTMENT-F Of' LtUILDTNC INSPECTIONS
212 Main Street ' Municipal Bullcline
Northampton, Mass. 01060
WORKER'S COMTENSATION INSURANCE AFFIDAVIT
r
%vith a principal place of business/residence at:
C) 1
-- -- -- - - - Y fThone 7 �
(strce-t/ci ty!statc�z�p)
Clo hereby ccl-Lif; 1111,'er the pulls and penalties OF perjury
O I am an employer providinS the `ollowlM, "VOIlr,Cs compensation coverage nor Iny
employees working on tlii5 job:
(Ins=icz CornP'ny) -- -- (Polio,Numbcr) -- —� (Lzpirtion Date)
I IL a sole proprietor general contractor or homeowner (circle one) and hzve hired
the contractors listed below;vho Have the workers compensation pollcies:
(Na-me of Contactor) (Insur mcc Comnany,Pohcf Number) (Expiration Datc)
(Name of Contractor) (insurance ComJaay/Policy Nt!mtrr) (Exoiraiion [Date)
(Name of Contractor) -- --(Insllr ICS CompanyiPolic}� Numlxr) (,!�z;;ir,:tion Date)
(Name of Contactor) Comrrrly/Policy Numb-_0 Date)
(attadt id�iti cot it:!k-ct if t:ccc:n r:t:�ixl.;cS<i.�:x tnr'i oc:,.ata iain,�:�e11 o=c,ador)
i
d) I illTl 1 SOIC prOp[letOi t1lln haVC I1D OIlC 'a'Orklllo 101 me.
11ii1 a home OWI1-1T oci orll]In-, 111 rile NVorr: inySCaf
N0,I1::Plcvsc be nNNWC that�:ilc kx<ko ;r_rs s o r.:yl ry tr T ;s c; r. n cc =,n:r.:C_:m Cr I.Palr oiS;c:.:
not tnocc th.n tluco unit+in u{idt Lk l our s m: w Cr oa tl un rurtcr r1 LtX•t-to r.r txt C fxrillV ccc�:ci_r:d:o t`
cniploycr3 uryV,cr llr.tvarlci ca :;atica Ar (GL152 31(3)),zP ,l:_:tic; by a hociro«-rr for a Ucra c cr Pcf:t:::r.:r.v c.:c rc Lv
]rgal ct�hu of an omployoc under tLe W«lccla cornpc)nA6on AcL
I ur,&mtund tli i a copy of tluu ciutca:cnty bo for�-nrdod to tlr Ds t.—A of Indic.trial AC6&n&Offl—of for tlm
coverage vcrificatioo and[tut failure to t<atrc covcraso urd-r section 25A of MGM.152 can lead to tho i-Position oCcr n 1 Pcr.ill:a
covsisti g of a f m Of UP to S 1,300.00 an Cir irnprixx Iw_ri of UP to on.yzar a.A civil peruldo in dx Conn of a step Work Onir_.-a:.d a
fino oC S 100.00 a day 1g,-6mi ar_
1 - Foe der;atrrxrtul uw«try
Permit Number
t
,I Lot r
Si pure 0 can &Pcrruittcc — UnZe
SECTION 8 -CONSTRUCT,ION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
e-,N r-,,-,
Name of License Holder : -� �� �� -J 7,`_J,
License
}US /per
D ;1� --
Ad!r ss Expiration Date
t
Signature ` Telephone
• "°°�``"
Cont Not Applicable ❑
��Re�fstered Home Improvem'e`nt ar ctor��. "°��a �` ` "'` � `�
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.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....... ❑ No...... ❑
,�sh,� �1s$� � �, ,a��.�
1:1 �,H O�wififflmemption
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinlls 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 fer 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
SECTION 5 DESCRIPTION`OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing 4�I
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work `%��—'1 h � §l?�. '± — `'�''-__ �� J_' i'6-,CIC z ! 7 - ---
Alteration of existing bedroom __Yes �' No Adding new bedroom Yes No
Attached Narrative L] Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet ❑
sa. IUNew"house"°and or"addition to existing F ousinir, complete'?the folloWing_
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
r
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 BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property
hereby -authorize _ _ to ac; ors
my beh-alf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner/Author rzed Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my
knowlecge and belief.
Signed ender the pains and penalties of perjury.
Print N27e
Date
Signature of Owner/Agent
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:
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 YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book _ Page _ _ arid/or Document #
B. Does the site contain a brook, body of water or wetlands? NO u0N'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
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location:
pip eat ser
Crrtywof-Northampton Status of Permft �:
+E
_ i[d'ing Department Curb Cut/t7rve',
2112 �Main Street Sewer/Sec atlab ty �
AM
doom 100 1NaterlWell vat abltit}r .=
`Northampton, MA 01060 Two Sefs ofStr �cural'P ans. ��
___ h�_u 413 5817 1246 Fax 413-587 12 112 Pfot'/Slfe Plans
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
li 1.1 Property Address:
This section to be completed by office
2u1 - '• > L l t 't`_> � .) ? Map_ Lot Unit —
Zone Overlay District
L
2.0\j
_ Elm St. District__-_ CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
i Narnr, 'Print, � �) � . i1nc,Address_ - — - -
2.2 Authorized Agent:
� 1
SECTION 3 _ESTIMATED CONSTRUCTION COSTS l
ItC'm Estimated Cost (Dollars) to be Official Use Only
completed by Permit apply cant
—
'�' ing (a) Ruilding Permit Fee
time ted Total Cost of
from 6
J P _r.nmg Building Permit Fee
1
J. Fig� Protection
eck Number
This Section For Official Use Only
Building Permit Number: _ Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
..
BP-2003-1127
G1S#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: BuiidinQ
Category: BUILDING PERMIT
Permit# BP-2003-1127
Project# JS-2003-1779
Est. Cost: $800.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: ED JAZAB 050099
Lot Size(sa. ft.): 34281.72 Owner: BRANCH YVONNE H TRUSTEE
Zoning:URA Applicant. ED JAZAB
AT. 24 HILLCREST DR
Applicant Address: Phone: Insurance:
9 SHEPHERDS HOLLOW (413) 586-2765
LEEDSMA01053 ISSUED ON:6111103 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE PORCH 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• Receipt No: Date Paid: Check No: Amount:
Building 6/11/03 0:00:00 2114 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo