17C-110 (4) 1
¢CttAMA
.Cr;zfy of Xort4ai tptnu z
z
B � �t8ss��h��g�tts
r� DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNM 108.3.4 to
act as l:is/her construction sups:: zisor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a one or twofami
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 r',egulations. 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
require"DEY ntil such time as the proper permit s and inspections are
made
understand the above.
(H ature requesting exemption)
I wil call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
_0
F e {rite of Part 11alltpfoi1
A _ E
'al csanchrtrCIIS,
DEPARTMENT OP BUILDD,,,C INSPECTIONS
212 Main Strcct Dfunicipal Building
Northampton, Mass. 010GO
wOruaIZ,S CON'Q'ENSA'nON GgSUT CF- AF MAVIT
(li ccusxJperm�tics)
\with a plirlcipal place of businessfresidence at: —
(phonc�')
(ar=lci ty/stalr fa P)
do hereby terrify, under dic.pains and penalties of perJw-y, hzt
( ) I am an employer providing the follo%ving-, %vorkct's comocnsano, covemSc for my
emplovices worming on this job:
(rinLr--n=Con? v) (PQUC-, ?:L�rr_r) --- ('':-pirrtior.D2j--)
O I am a sole proprietor, general contractor or homeow-Oer (circle one) and Dave hired
the coot actors listed below wbo have the folio%vi p, workers comoen-saaon pcLcies.
(Nam: Of Co^'^C-,Or) Gn-s!r,ncz CoInpan)-/P ouci ?,,tutrLC-) -- �`:JIFd;!Qi'.1111C)
(Name of Coocra'c70r) (]nslrane; Comnaa`v-PoLC Nuncer) (%-,tir..6on Dale)
(Name of Cou=C-10.) Ozswanc; Company-/Polk}• Num ter) (Expimdon Date)
(Name of Contractor) 9-asufanat Comp, n IPolicy Numtrr) (E��irtion Datc).
(sII.ich..t�:�oc�1 cScd,irncca.�•to inch inform�oa pctn.inia5 w.11 ooa7-_c"�:�) -
{ ) I am a sole proprietor and have no one working for me-
( I am,a home owner performing all the work myself.
I/V NOTE:plesc lx csvate th,.�i:.1e hcmr._oµ ,,KtO csxplay pe-com w = C=-. -20 a trPt.u,.-ork as a d..c.lL^L of
ant tncct than t 1u—,J in 11-b�the hom.,..r tteda a oa the p-ou c z�puttea:r_thcea r. ax C=_� _Uy ocr--.& d to be
—Plor--s the .0 :c=.k-- o.A,:: G l.-1 S2=1 S
( ))�:-{.plictDOa try n bommavcr fc a lies_-or unit rz=y-id—tl:e
legl n�u of en cgloyx u &-c it-Work ds Ooazpoovt;po Act.
I undo.-zZaad thG x copy of tbu cat--u=Iy be for.--Jnd to tho Dcpnrtmcat of Iah+.s'iicl Acadc Off-of L1-u+noe roc tho
covattsc vCr'fjctioa And thi L•iltac to so�uc'covcrt tnndC s 1:%iCa 25A of htoL 152 cma ltd to the i=pozai-of cimiasl pcatltic�
oowi n2a of a fine of up to S 13oo.00 andfor 6=pri5otsOC=of up W ooc y-. tzd Ci it pcwhi m rsc roan of a Stop Work Orde and a
f=0(5100.00 a�jf
For L7+nm��1 u,c on7y
° permit Numbcs
Lot
Si Zinc of Lic=LsccJpcnT iUr-C Date l
SECTION.8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9 ,Rester"ed Ibnie lrifayeiienfiContracto � y-. . • Not Applicable ❑
Company Name Registration Rum er -
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...... ❑
11:Y. onli wnergil Exemadon
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 buildine 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"certi d assn responsibility for compliance with the State Building Code,City of
Northampton Ordinances,State Loc Zonirpg L ws and State of Massachusetts General Laws Annotated.
- -
Homeowner Signature
r
i •
SECTION 5-DESCRIPTION:OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement
�„�Windows Alteration(s) Q Roofing
Or Doors y
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[O]
Brief Description of Proposed
Work: ������I� e� t] 7t M9
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa:[ 'New-)rouse and orctdition to bxf stii hoirsn corer lete-thefoEfow�i
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? fikD
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-,TO BE COMPLETED WHEN
OWNERS AGEN7011 CONTRACTOR-APPLIES FOR''BUILDING.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
l 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
;k i.000
Sign u of Owner/ Date
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
- f
Lot Size -
Frontage -
Setbacks Front
Side L: R:' L RE
Rear
Building Height
Bldg. Square Footage % 1 �-
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?
N0 Q 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 0
IF YES: enter Book Page, and/or Document#' _
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW Q 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 Q NO 0
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 - NO Q
t
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
a
City of North ampton StatsPenrx � �
--- Department CCit JQutIQ trewa Percrar
t- M
MR
' Main Street SWereptt Vtr tt�t �
r oom 100terlWeEfvattahil► x `
ort, ton; MA 01060 Tulio bets QfStructc raEPfans� �� � �
NOV �fionX� 3- $ 1 40 Fax 413-587-1272 PtotdSlteFlans; `
AIT_EI6pjkllb ,; , UCT, LTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed ..o.,,
1.1 Property Address:
Lot :Unit
,.�—. Zone OyeriaymDistrrct
, EImSt°Distrrct = CBDistFict
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of cord:
rr c K
Name(Pri nt) Current Mailing Address:
Telephone
Signatur
2.2 orized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed b permit 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) ��GL�.�� Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
24 STILSON AVE BP-2005-0620
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 110 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0620
Project# JS-2005-0826
Est.Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 11456.28 Owner: MAHAR PATRICIA A&PATRICK DIGGINS
Zoning.URB Applicant: MAHAR PATRICIA A & PATRICK DIGGINS
AT. 24 STILSON AVE
Applicant Address: Phone: Insurance:
24 STILSON AVE (413) 585-8756 ()
FLORENCEMA01062 ISSUED ON:11129104 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOW
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 11/29/04 0:00:00 1203 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo