17C-080 (2) a
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�:. DEPARTMENT OF BUILDIJ,YG INSPECTIONS /=
'212 Main Street 0 Municipal Building
INSPECTOR 5'
Northampton,MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as hds/her construction supc< ,,, :>or. The state defines"Homeowner" as, ".Person(s)
who owns a parcel on which he/she resides or intends to be,a one of twoami -
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 wilding departmenf 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 backfil1),
sonotube holes (before pour) a roup-h 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
/ `D l understand the above.
J L
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued-to me. -
Daze
Address of work
location
F E �YZ J: ff ��Ij�llt�]fDl1 -
A l E c3aachnrcIle• _
4 DEPARTMENT OP BUILDr3\'G INSPPCT1Ot.'S -
212 Alain Strect ATunicipal Building
Northampton, Mass. 01060
Wofuc:IZ'S CONIPENSATTO.N LNSURANCE AFFIDAVIT
I
(1i ccnsxlpertnittcx)
With a principal place of business/residencc at:
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(l hone-)
(su-�.t/ci tylsZalch p)
do hereby certify, under che.paint and penalties ofperJury, hal
{ ( ) I am an employer providing the following lworkerJs comocns-2:30rl cove,ge for Iny
emplovees ivorang on ties job:
t ,
(Instir�c Conrad.) (Polio-,-Nt:.mbcr) — (r:pir`dor, D21.e)
{ ( ) I am a sole proprietor, gcaeral coarractor or homeowner (C'Llcie one) and bFve hired
I
the contractors listed below wbo have the following worker's comoep_saaon polxies.
i
j
(IN amc G COntMcior) On uraric colnpanl .filobc•' NIUM1 <:) (E41r'JUOn D:11c)
(Name of Contraor) Qnsufzncz Comnazw?oUm, `umc_r) (Ex pirlion Due)
(Name of Consaaor) (Insurdn<_-- Compan}•/Pout• Numhzr) (Expiraon Datc)
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(Name of Contractor) Gasu== Comrzay/Policy Number) (_%pIMI ioa Datr).
-- --
(ats�.-1:d3i�oc5.1��.ir ncc��_-ti•w a�cjucL iafoc�.ii oa pctniaia6 to.11 ccu-�-tn:�)
I
j O I am a sole proprietor and have no one working for me.
( ) I am.a home oNvner perforrtvng all the work myself.
NOTE:plcsc be c a arc r*• +f lG bcmco.xa ty employ P�_U yy to C=' _.m c rrya r-uric ca a d..-It:^;:of
ant mcca'ht'-nr_iU in%rich the bocxo-wc road=oc oa the Qasad3 zppsrt,==tbeeo�•c ox C=>xay a cd.-oi to be
t -avloy—uar'.e the jai c:~s o_:tipe--- oa Act(G`L1�5�2�-�n��l(3)1,n.ppti�aa by a bomoavcr fc a 6--`v-a permit rr_y a id—the
Ic-g1 R.n,.Of-=c'�loyx uodcr da.o Wocfalc Compaoaition Act '
1 t>•odc^rt+ad tba a Copy of thi.c==orm my be for xnrdsd to tba Dryartmmt of Io,d..uicl Mcdcsa'CCof Li.—far th.
eovezbe vcrlc=ioa=d ttu Utam to s==tcovcMZc tmdc soetioa 23 A ar MOL 132 can lmd to the iaxssid0a of Cri ic-11 pca+llio
eoaxirixxg of a r=orup to S 1 Soo.00 and/or of up to ooc yr1 nod avil pca.tia in tSc form or.Stop Wort Ordc—d.
rrrr of S 100.00.dzy cpjc:a me
For dq,-e
S'F��of Liorrsc-JPcrmitt� e I l
SECTION 8-CONSTRUCTION SERVICES 7
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
I `IRdds are c E ct itue Ting€ eat rertt i ras '. Not Applicable ❑
Company Name Registration Num er - --
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSAT,104:INSUONCE AFFiDAVLT$(M.G:L.c t52,,f 2SC(i
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-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 shalt 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 unde -this permit.
The undersigned"homeowner"certi es and assumes responsibility for compliance with the State Building Code,City of
orthampton Ordinances,State and ocal Zoning aws and State of Massachusetts General Laws Annotated.
omeowner Signature lL
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SECTION 5—DESCRIPTION OF PROPOSED WORK(check altwylicable)
New House ❑ Addition ❑:;. Replacement Windows Alteration(s) ❑ Roofing [�
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[O] Other[O]
rief Description of Propose
Work: �JV/y O
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sal evi ro s a' it xcs n ea O eke i' , a s Inn:
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 Ta-OWNER AUTHORIZATION TOBE COMPLETED.°;WHEN`
OWNERS AGENT`.OR CONTRACTORvAPPL1ES FOR BUILDINGPERNtIT
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 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 p nalties of perjury.
P' t Na a`
S u of Owner/Agent Date
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Section 4. ZONING All Informatioh 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
E �
Lot Size
Frontage
Setbacks Front
Side L: R:— ' L: 2 R:I
Rear
Building Height
Bldg.Square Footage — % 3—
Open Space Footage % —,
(Lot area minus bldg&paved
parking)
t-- r
#of Parking Spaces
Fill:
1 i
volume*Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES Q
IF YES: enter Book 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 0 Obtained 0 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 0 NO 0
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 0 r NO 0
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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..pity of Northampton
Building Department
"212 Main Street
Room 100
Northampton; MA 01060
,.. 0"`
V phone 413-587-1240 Fax 413-587-1272 to
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APPLICATION TO CON STRIJCToALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
S CTION,1-SITE INFORMATION
N k
This sectwrr to be comPietecb once
1.1 Property Address
e
Dkstrrct
(v V 1 4
y
n �
SECTION 2-PROPERTYOWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
,<�ftA<%k 6, 1 F --Yl N t� e)� . a-L 010�2-
ame(Pri nt) Current Mailing
q/ddress:
CP cp
' Telephone
Signature w
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
completed by ermit applicant
1. Building b U I� (a)Building Permit Fee
2. Electrical U �!/ (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building,Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
i
6. Total=(1 +2+3+4+5) Check Number
This'Section,Fdt'Officiaf, Use Only
':Date
Building;Permt Numbers Issued:
Signature:
Building,,Commissionerlinspector of Buildings Date
39 HIGH ST BP-2006-0522
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map-Block: 17C-080 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category_ BUILDING PERMIT
Permit# BP-2006-0522
Proiect# JS-2006-0775
Est.Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin Homeowner as Contractor
Lot Size(sg. ft.): 7797.24 Owner: SIFF WILLIAM D&SARAH K
Zonin :URB Applicant: SIFF WILLIAM D & SARAH K
AT. 39 HIGH ST
Applicant Address: Phone: Insurance:
39 HIGH ST (413) 625-8167 0 i
FLORENCEMA01062 ISSUED ON.111812005 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WOOD 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: OX /111 g l S L 0 ut S
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATION .
Certificate of Occu anc � l/
Si nature•
FeeType: Date Paid: Amount:
Building 11/8/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo