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DEPARTMENT OF BUILDrXG INSPECTIONS /
INSPECTOR '212 Main Street • Municipal Building '
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to
act as l:is/her construction supc.-,.,A,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 fame y -
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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tw-tnT
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o DEPARTMENT OP DUIL00\0 INSPPc710A'S ;
212 ?`lain Strect Itsunicipn! Building
Northampton, Mass. 01060
WORIG:-R'S CO'NQ'ENSATTON ONSURACE AFI'Ln�i�TI�"
-
�I (Ii ccnsxlpermi tTcc) _ - ._ -•- —--
v.9th a principal place- of businessfresidence at: --
!� P�hYt o �.(C_ jJ ten- S t79ic�� (Ihone')
(str�t/c�rr/stalLta p)
do hereby certify, under the,pa-'M and penalties of pegury, hat
an employer providing the following'workcr's comocasado, covemge for lily
eluplovices woriong on this job:
(MUT-_n=Conr�cl) (Feuer Nu_mbcr) -- (:pirz or. Dau-)
i
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O I am a sole proprietor, general contractor or homeowner(crcie one) and have hired
the coauractors listed below who have the follotvine worker's conoen_sation policies:
('Name Oi COntrncior) (Insurance-. Cornoanyoi auc; Numh--:) (RX)1rd13^n hate-)
j
(Namc of Cootramor) Cbsurancc ComDan`iPoUm- Nuncsr) (-Ei-oir,lion Date)
I
(Name of COI1rraCto;) (Insuranc; Company/Poliq• Nun-bz) (Expiraoa Date)
I -
(Name of Contractor) (Losuranc-c Comran-y/Pobcy Numb-`r) (Expir,6oa Date).
(atl�.c'b�ditoca!r!x--.ifncc.-....-•to arc infocmiioc P=I iai g L0.11
a sole proprietor and have no one working for me.
( ) I am,a home owner performing all the work myseff.
NOTE:plesc be etrlr Ti—N e DOTS Ki> czap pCZaoaa LO dJ C• n essx�oo c rgaa.vori w a d..r1Lg or
not moca ibex tlxm t_ata is wbicb the bomoowoc rcaado oc oa the p' uo6 zppurtcu_r1 tbeen L-c nOt C=�. Wy oecs:d=-OJ to Lc
enployea uode the.+a i cfz c=:p - as An GL152�1 5
t ( )}.:Pptin.00n by.bomooavcr rcr c licz=or pcmit cr=y cidmc+c t1:c
IC-P1 et vZSC of na—Player coder die Wortcol,ComPcmat AeL
[undestaad 6a D.Dopy of lhi.mt.emem mey be focv.nrded to tbo Detxnmmt of]v�.tsicl A.,odcm-?Ofsoe or Gaur+nee for the
covcxse v estioa ate llu LilLre w soauc bov �tnndrl soeiion 23 A of}(aL 1 S2 na lad to the i aiposi ioa of criminal pc=16cs
eoa'L'Mi g of i fine or up 1051}00.00■rtd<or OC uP to ooe ynr e.od civil pca.huQ is 6e-roan or.Slop worti Ordc.ad.
figs of S 100.00 a dsy tp.iau tnc
I For ^
permit Numbc-r
( e,5•--- 1.�p� Lot
Sigma re- f Uc=isccJPcrtniucc Date J
SECTION 8-CONSTRUCTION SERVICES i
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
8°2e s exe , .ornei emei Not Applicable 11
Company Name Registration Num er - ---
,. G k plod_- 5 �7 d� o4
Address Expiration ate
Telephone,. c
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT`(M:G:L. §°25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application.f=ailure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
",W& � mr: a
� �e �
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
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SECTION 5_S CRIPTION'OF.PROPOSED WORK;(check-alf-ayOlicable)
New House [] Addition []; Replacement Wjndows Alterations} Roofing
Or Doors ,m__
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks (M Siding[tom] Other[o]
Brief Description of Proposed .,
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No -
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa>if>Ne o> se an ditiop#a exlstin- oustncu.coma e ev a 0 OW--►nrt:
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-`O.WNER AUTHORIZATION-;TO BE COMPLETED;-WHEN,
OWNERS AGENT;OR CONTRACTOR'APPLit FOR BUlCU1NG 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
as C)wqvO-
jr Authorize��d
W
hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my"KffM 5dge
belief.
Signed under the pains and penalties of perjury.
_J
Print Name .
7
Si ure of OMCfA4e t Dare'
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Section 4. ZONING All Informati6h 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
Lot Size `
Frontage
Setbacks Front
Side L:? R:' L:+ R: �!
Rear
Building Height
L
Bldg.Square Footage %
Open Space Footage __ %
(Lot area minus bldg&paved
parking),
#of Parking Spaces
Fill: {i
(volume*Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO ® DONT KNOW 0 YES 0
IF YES, date issued:`
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES t
IF YES: enter Book i Page, and/or .Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
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 0 NO 0
i
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: k
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 0 NO 0
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IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
IGity'of Nortf ampton
,building Department
4
212 Main Street
Room 100
Northampton; MA 01060 .A
_phone 413-587JI240 Fax 413-587-1272
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- APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This ect�on xo be ca mp1eted bx AF
1.1 Property Address:
_ Zone � � x Overlay Uistnct
bEfrn District a, C&District
SECTION 2'-PROPERTY OWNERSHIP/AUTHORIZED'AGENT'
2.1 Owner of Record:
J b -.f , C 1` L
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent::
: ZT�r-J p-1GCfC.
Name(Print) Current Mailing Address:
—kb Y 7�
ture Telephone
SECTION 3-ESTIMATED tokStkuCTIOW COSTS'
Item - Estimated Cost(Dollars)to be Official Use Only
completed 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 Check Number
This Section,For Official'Use Onl
Building Permit Number` IIssued:
Signature:
i
Building Commissioner/inspector of Buildings Date
35 HIGH ST . BP-2005-0983
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-078 CITY OF NORTHAMPTON
Lot: -001
Permit: BuiidinQ
Category: BUILDING PERMIT
Permit# BP-2005-0983
Project# 35-2005-1357
Est.Cost: $750.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq.ft.): 8929.80 Owner: FERBER JUDITH A
Zoning:URB Applicant: John Corbett
AT. 35 HIGH ST
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:4 112105 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL 4 VINYL DEAD LITES
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 Occupang Shmature•
FeeType: Date Paid: Amount:
Building 4/12/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo