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DEPARTMENT OF BUILDITIG INSPECTIONS �
INSPECTOR '212 Main Street • Municipal Building '
Nordiunpton,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 his/leer construction sups .visor. 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
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 oTNorthampton 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 nour), 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.
(Ho�m.e -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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DEPARTMEI-T OP I3UILt)r3,,,G INSPEGTiolls
j 212 Main Street Municipal Building
I Northampton, Afnss_ 01060
I
«'C U Llt'S CONQ')✓ItS S'ION GzSUR CE A l'TU��iVZT
---
%IVILb a principal place of businessfresidence at: -- --
honer)./
(sa rJ/szaulriP)
do hereby cercifj, under t11e.pzint azd penalties of penury, hit
( ) I am an employer providing the follo%vine'-vork-cr'5 comocnszdor, coverage for 111 `
e-mplovees wortang on ties job:
�c Con - -- - _
(Incur ) (Pone- ?:��ixr) (r;pir�non Dom_)
( } I am a sole proprietor, general contractor or homeowner (c cie one) and have hired
the coniractgrs used below who have the `oilo„vino worker's camoen_snion policies:
i
(1+=C Ot Cont=cror) (Insuranc;: Cotnpan)-/Pout, Date)
(Name of Coneaaor) (Insuznec Comoa -VIPojc%- \amc_r) Dne)
(Name of Contractor) (Imsuranc: Com f%G- Number) (E•Npir:doo Daic)
I
(Name of Conaaaar) (Insuran Comcagy/Policy Numb r) (Expiration DaLc).
(aII�[sl:d r Dealc�,ifncc�a_^c to a�cu inform,zion pctesains to.17«cso z)
j
I am-a sale proprietor and have no one wor�dDg for me.
I am..a home owner performing all the work myself.
i ,��
NOTE:pl=.=be cwzre t+'..N,-.0 bCmeo czen Mbp C=plpy to fSJ cs,c.,00 c rrzir woo t C1 a d..rt1_�of
got mere 0— urs in cc3,riob the bomaovw-o r r=id=oc oa the y Dunes:apt rtes m the,=ox to be
e�pioyea uv—. the -..,,r--,:oa Ace(GO 52=1(5)),=PpUa.600 try.bommaaa fa a lip.or pcmn=y e-,dco=tie
lcFj c_^„of en esal.yw untter dw Wotk-e-C.o�ora.iioa Act_
- 1 und.c—f-4 tb.a a oopy-r Lb;-cnt—my be foa>..rrded-the Dcpanmcot of in&u ial A.&..Iy OtG—of r+—fat tb.
oovcae^c--'L-:"ioo and Ih t L il,ac w +rt bov1�1=dc sxlioo 25 A oI MoL 151 m Ir:d to the iasaosition of cimias!pcvaJlia
eoa s ixzg of a fioc or up to s I}oo.00 artdlor 6=prjjc=Dc=or up to woe yr=r e.od c.i1 pcmjj*ie in dx room or.Slop Wort Ordc aad
fi=of S 100.00 z d_y Lplazt me
For de�.., vie only
. � pCTIIIIf N�I u=tiIDt---
10 � �,� A•Lz p” -- Let R 1 ,�'
Signaurrc of Lic--nscrlpcm-Lju= Ce
SECTION 8-CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: ( � Z
License e Number
1 n4f o ra Q — /0115
Address Expiration 10ate
335
Signature Telephone
9�=Rie"°"isfere�Ho�rrre:'Im-�avemeC"o�fraEa' `' �• �.,: �`K-m�� Not Applicable ❑
l r6m Company Name es0
Address Expiration Clate
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G:L.c.152,.S 25C(f))
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...... ❑
W
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 A,miotated,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-DESCRIPTION OF PROPOSED WORK(check all applicable]
New House F__] Addition F-J., Replacement Windows Alteration(s) Roofing
Or Doors D 1 9
Accessory Bldg. ❑ Demolition ❑ New Signs 101 Decks [M Siding[0] Other[ID]
Brief Descr'pti f Pposed
Work: 4 Ac /f-* 74 , eW51q AlIECA-)
Alteration of existing bedroom Yes_ e No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
a �•;' -z3*'.,. �-: .� `s+ =r,;.�.'i°at m�-a _ ' w.''^�..:.�.-"^raw r ,F« ,"�i `& —.,scn,3
sa �f��lew��ause ,�d�ci �dt�tO:extstli �.�oeisir>FC�,:�or�g���e�h �ar[tQUrr•l>�g:
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-'OWNER AUTHORIZATION-TO BE.COMPLETED WHEN
OWNERS-AGENT OR CONTRA`CTOR`APPLIElS FOR BUILDING.PERMIT
as Owner of the subject
property
hereby authorize ` air
to act on my behalf,in all matters relative to work authorized by this building permit a plica'on.
'gnature of O er 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 penalties of perjury.
xzlke UVc 7n^l
Print Name
Signature of Owner/Agent ate
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
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
A. Ha's a Special Perm it/Vahunoe/Fndi � mnerbeenissuadfor/onthesite?
NO W DON'T KNOW 0 YES 0
�
IF YES, date issued: /
IF YES: Was the permit recorded at the Registry of Deeds?
NO K J DON1KNOxv 0 YES
IF YES: enter Book Page; and/or Document#S'
�� ��
B. Does the site contain u brook, body of water orm/et|unds? NO ��/ DON7KNOVV �_� YES �~�
. -
IF YES, has permit been or need tu be obtained from the Conservation Commission?
'
Needs tobaobtaloed v�� Obtainm� x�\ 0mta |ssumd'
v�� v�� ' �
C. Do any signs exist un 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 0 NO
' v
IF YES, describe size, type and location:
E. Will the construction activity disturb m filling)over 1 acre misdpart ofo common plan
thawN\dimurbovnr1onm? YES K ) r NO Alh
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i
ortf ampton -
�ln
i !Department
_.� 2 in Street
2005 m '00
North
OCT 1 Mrs
h',m
8 pt n; MA 01060 Tu+,oa Struoitxraf Pains F
phone 4a 37-12 0 Fax 413-587-1272 Pto . fan �
I 1 i iseFcrlons a
j DES OF Bll_ta NG Cher geci a
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CATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 --SITE INFORMATION
1.1 Property Address: to be completed b,4ffice '
This section 4
/ 5 6F (CL4 � Lett Una
F-60k,ewict MA5`5 , 0(0(-, Zane Overlay;`D�sfrrcf
EI[t Sf District CB District „.._
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2 l�(/l�lf0it'r2� �icli^
--i4Ce w4c'-04 /Ilk, <oc�.-/rte' �2�� �ftli�l T/�<6 Tamil rw.
Name(Print)
V Current Mailin Address:
Telephone
Signature
2.1 Awihe imd ft— . 01,0N69 0A/ BRA
Name P' Current Mailing Address:
e
74�03
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION 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+5) Check Number
This Section iFot Official Use Only
Date
Building;Permit Number-
Signature:
Building Commissioner/Inspector of Buildings Date
W.
19 SHEFFIF_r_I> [,ANE BP-2006-0422
GIs#: _ COMMONWEALTH OF MASSACHUSETTS
Map:Block: l7(' - 116 CITY OF NORTHAMPTON
Lot: -001
Permit: F�uildin
Category: BUILDING PERMIT
Permit# P-2006-0422
Project# -2006-0616
Est.Cost: S _1
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Clan_: Contractor: License:
Use Grontj_ Jack Walton Construction 107687
Lot Size(sg. 1! i 1798.80 Owner: KENDREW JOHN F&ELIZABETH A
Zoning: Ul:_ Applicant: Jack Walton Construction
AT: 19 SHEFFIELD LANE
Applicant css; Phone: Insurance:
130 Coup? :id (413) 667-3358
HUNTIN j MAO 1050-9727 ISSUED ON.1011812005 0:00:00
TO 1Jr. ''RM THE FOLLOWING WORK.-STRIP & SHINGLE FRONT BLDG
POST rl''` ' ' `,RD SO IT IS VISIBLE FROM THE STREET
Inspector � ilig Inspector of Wiring D.P.W. Building Inspector
Underg r w- 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 P1'" " MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY Ol,' : "ULES AND REGULATIONS.
Certific�t ' Ic'cupancy signature:
FeeTyhc: Date Paid: Amount:
Building 10/18/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo