17C-144 (3) ¢'SlSAA1P�.
Crier of Wort4autpton
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<s DEPARTMENT OF BUILDI],,TG INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building
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 his/her construction sups-•'is 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 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 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 roject until such time as the proper permits and inspections are
mad
I, understand the above.
(Etome owner/resident's signa a requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date e-1 — � — 0
Address of work
location
g 6 Eiiaaarsciflcsrtls
� 11
DEPfuZT1.,-?NI OF BUILDING INSPECTIONS
212 Main Street ' Municipal Builcling j
Northampton, Mass. 01060
WORKER'S COMTENSATION INSURANCE A-MIMANIT
(lictins°Jr�rmiluc) __..__�--
:ith a principal place of busilless/re:;idenc
tTC,ticitf:; :rani)
CIO I1CfCUy CCi'tll}'. L "c-1- the t).!M:s ,1110 PC11?1i1CS Oi �f.r�U111 iI1F1i=
I am an employer piOvidan- the 10110"':illt %OIt;CI s COttII)Cns5'U0I1 EOr Iry
cmployces wor4drig on tills job:
(InslranG Comp am,) J (--c' Number) —_— (Expir::tion Date)
l j I am a sole proprietor, genera ccnm-'Ic_cr c: homco:�ner (ci cle onei and ;1a,'e [lirec
the contractors 1lsted be.0w 1010 ii ill f0!l :P er e
OCk S GOt.m-pt of ;?0
(Name of Ca.,inctor) (L1S acc Coln^:::;,;Policy tlujn�Rcr) (� :c Dotcl
(Nam- of Contractor) (711simn.c: Co=D_:'N/Pe'!icr Ntlncr:r) .anon Date)
(1"'Qmc[ Of Conuactor) (lrls' ni1CC COw;_]}%PO�;C. TVtIIIi�7 IJ -- -'..l" ,,":ii -r. Datc)
- (Name of Contractor) -- - (Ins allc� Conlr .�;POiier Numr�*) (H--c -:UO Date)
( 1 il?II <'. 'sole 1?I Ul?r1CtJi c'ail"? ill?''G no 011 U! aril; t0r -11e
;fill < IlOII?e OP;(?C. iiC?:�1"iilli? 111 i'_... •�', . ..: ii.` °;.lt.
N0,11:picaac tY an-arc tlsr. ilc tx<:moo 1rn t -�c:::pl ,+I*:`" :_.r'rV3nc�a:: n m rr:;'air «cIL g c:
not mocc lh-n llzrcc units in%%-Izdt SFr f :-. ,.ir.=,I=:';zz a-a;'`u mx cc'ySa1I'i o:�: :o h
�Z'.plcyc3 un"'-r tlY r�r:((' !I.2 s!(S), .c.area; y a t of.councr`cr a l cc sc a
Icgal ctztua of an a=Xploy.<under tLo VJoc?<c�c Corz-;,or-_.+.lion
I undczzwd dale!a cmy of diii cza c:x•ruAy to fotw,vdaj to v»IYtxi t:xn of Iz d L iJ Anir�tf Callao of:: ri r_a for tix
ooV=&c vc ificlion and that f_ilurc to_- .:c ro�cr_,.,uc.k.-.c'z,ic'•t 251,of?.{Gl.151 can Iul to the
cooiisIing of it fssr_of up to r 1 500.00 a:�.".'cr i^:;ri r.Z t:1 of::p to Cr.--y .-,j civil pcmI,c in�c f0071 cf a
fa-of S 100.00 a dey art.imt mc.
FI-I i�;ut z��ts1 u.c cr:l y 1
perrnit ------------------
Sit;naturc<�f i.iccsx,Jl'crnti;tcc. _. ->-;:: - i F
SECT ON 8=nCONSTRUCT!ON SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
' Re fere olm r ein'enCon�`°#ra;tor.•- : 1
. _. � r. ._._. Not Applicable ❑
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...... ❑
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 Annotated,you may be liable for person(s)
you hire to perform work for you under this permit.
The undersigned"homeown "certifies and assumes responsibility for compliance with the State Building Code,City of
\ Northampton Ordinances, ate and Local Zori4- v nd State of Massachusetts Genera] Laws Annotated.
omeowner Signature
a
SECT,10t5. DES�RIPTLON OF PROPOSED WORK checkalt,a Ircable
_.,x.,;."i "�r� ,�"..�.+'�#"�i '�=.,e�w.r+4"',u;fa :".�'..: .,_-+._'a'_ '. r>v.. :✓"' T' .;: 7°: E�. ,a:
New House ❑ VAddition ❑ Replacement Windows Alteration(s) ❑ Roofing } .
Or Doors ❑ /
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding[ Other [ ]
Brief Description of Proposed Wor : �rt ie 4 ,s4i P,) G L E 6
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
6a
I°f NewlIi se1aWd06 ad`di.I on to ezistin�;t ousin? complete fheffd'fi&n:
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 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; OWN AUTHORIZATION "TO BE COMP LETED:V ER HEN
OWNERS/GENT OR CONTRACTOR APPLIES, FOR,BUILDING:PERMIT ?':
3 N
l as Owner of the subject property
hereby authorize to ac, 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 penalties of perjury.
Print;Nanne Signa of Owner/A ent Date
i
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
I
Lot Size
i
Frontage
i
Setbacks Front
Side L: R: L: R:
Rear
Building Height
i
Bldg.Square Footage %
i
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 DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DON'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:
City of Northampton
Building Department
M ..
212 Main S treet
Room 100
Northampton, MA 01060cie �
phone 413-587-1240 Fax 413-587-1272 k
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
This section to be completed'by office
1.1 ProoerttiAddrejss: f
t#ntt
t
'Zone ' Overlay District
.,*Dm St."D�stnct ',`CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED-AGENT
2.1 Owner of Record:
t ST
Name Ant) Current Mailing Address:
�/at��A m7k �v Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SEC17ON 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 v (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) O C3 d 0 Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
40 KEYES ST BP-2004-1029
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 144 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-2004-1029
Project# JS-2004-1550
Est.Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10890.00 Owner: MATTESON PAUL D
Zoning:URB Applicant: MATTESON PAUL D
AT. 40 KEYES ST
Applicant Address: Phone: Insurance:
40 KEYES ST 0 586-6568 0
FLORENCEMA01062 ISSUED ON:4127104 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 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 4/27/04 0:00:00 1067 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo