17C-219 (3) O¢ttlAMp�o
Gl ity of Wort4ampton Z
1�H53A[1iliStttB � ' -
` 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 has/her construction sup,,.-,, ,or. 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
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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a e (rill of Port 11al11p!oil - —
gf �ZaIaAcflnsrtla'
DEPARTMENT OP DUIt1)f>\G INSPEcTlot"S -
212 ?lain Street Municipal Building
Northampton, Mass. 01060
wORTQ:R'S CO\III'I;NSATIO.N LNSURACF' AFFU),,-vr"
(7i ccnsxJperrn�ttcc)
VtgLh a pr-bincipal place of businessfresidencc at: —
(phone
(s�tJci ty/sta.tr.��p)
do hereby eertifjr, under thc.pains and penalties of pegu-y, :hat
O I ern an employer providing the followine , orkcr's comocns-n ion cove mac for Illy
emplovecs ivoriang on this job:
(Lesut---n=Corer n.) (Polk-: (_:-pir`uon Dam)
O I am a sole proor,eror, general cootractor or homeo-v r (c cie one) and have hired
the caniTaciors listed below wbo have- the folio%ving worker's pal!cies:
( +aII1C of Conm-acwf) (IaRrlllt Co1II03,i)-/otlCi ?,,Iu
- (Na me oC Coatr clor) (]slnUZncz COmDan}vpok—' Nuacrr) (E»ir6on Dare)
(Name of Contractor) (Lnsur-anc; Coml-=y/pouch Namb.r) (Expiraoo Datc)
(Name of Coatracior) (Lnsuranc-- Compaay/Policy Numb-cr) (Ea�i!<tion Date)-
(aII ]:.d1�oc�J L'cC,if ncCa..1-to c+c!ttd_taformL=Oa Pa-tx ins to.0 cum--CLO=D)
I am a sole proprietor and bave no one working for me.
( ) I am-a home owner performing all the work myself.
NOTE:plc=be co uc t>L K��]C t�C�1iaC 1 It,cplQy QC.,7=w do rcpair K-ork oo a of
Dot moc'e th_a t..'-^o:pi's in u'�i�Fbc bomoownc resid�oc oo the p-ou�z,�punea:r_tbe-ao c.-c noe�k:..11y oeeed—ci to Uc
citploycs ticttxKam{ ., Ac: GLtS2=l 1(5)),( )}.=•ppttca.6oa by n t)oil3eow-pC fc a 6�=IX pa-min cry e.-tdevec IEe
I'P1 ct-a+c or ea e=ployec wader dw Wock.Oe,C,.pornaiioa A L
I uadcrta,nd[hd a Dopy of lhii mtemcm may be foc-,,d<d to dh Degartaaeot of Ind`+.t-ricl Aendr��'otGioa or l+s;urzooe for th.
cove!a vcrif cztioa and dt-t L-iltae to ycaK)=%" S order S4c1jOQ 23A of h14L 152 can Ie d to the impp ca a(aimiaat peai$i- -
coast: of a fine oCUP to S i}00.00 Manor urr{aiyo oCup to Doe ycr Lod Civil pm.tia w be form of a Stop woric Ord=and a
Ctm o(S 100.W t d_y ap a"j
Far dcquta+l•t ux only
Pcrmrt NUML-r _
!� ).drip: Lot
`� Signature of Licr�saJPcrrniucc Uate -- J
SECTION 8-CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: (/\6Cr-1 PS P C-4-4, R K, e7 a/ 3f 0
License Number
�
67, QX 3 y t�i)S� �� c%/d ti�A3/c��
Addres Expiration Date
Signatu Telephone
9.wRe''is iec`Horne lm civei Yent,Contracta =x� `= ' _ gnm Not Applicable 11
Company Name Registration aum er - -—
Address Expiration Date
F-'12 f r'n� P C7/C� =2 Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCE.AFFIDAVIT`(M.G:L.c.162,,L,§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-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-DESCRIPTION OF PROPOSED WORK(check-all applicable?
New House [� Addition �:.: Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks (M Siding(pj Other[Oj
Brief Description of Proposed
Work: Sti r,; fs� s DV 1`l?llld
Alteration of existing bedroom Yes ✓1 No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
-.: r,�_ °z* °.
sat Iff eWtiho rsean +Dr ciititi'66A a existlncthod§1K_ .car�p et�:thec,foll&A66:
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 CONTRACTOR APPLIES FOR BUILDING 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 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.
>2i_1 G /t' LL19 Aft-
Print me
,X-zk
Signature f O er/Agent Date
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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
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&paved
of Parking Spaces
'
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
Ni 0 DON7KNOVV YES 0 �
IF YES, date issued:,,
IF YES: Was the permit recorded ut the Registry ufDeeds?
��
NO �� DON'| KNOW 0 YES
IF YES: enter Book Page-, and/or Document#
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B. Does the site contain a brook, body of water orwetlands? NO «�� DON'T KNOW �_/ YES �~�
IF YES, has u permit been orneed to be obtained from the Conservation Commission?
'
Needs tobmobtained x�� 0bta�med x�� Om�m [ssumd'
�~� «�� ' �
�� 0)C. Do any signs exist on the pvuper�? YES �_� NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YE5 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre oriuit part ofo common plan
that will disturb over 1 acne? YEG K � NO
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|F YES,then e Northampton Storm Water Management Permit from the DPW iorequired.
-e€-Nor t ampton
i Ui�ln�t9e�artment µe
Street Sev�e eti tl r[ = r
R=6 100
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� ; 1 "N&04am ;:`MA 01060 Tutio Sets o 5 r rural Plans=mss �� a
phone 413-587-1'240 Fax 413-587-1272 PIotJSlt Fans � `
t'_ ._. ._. �.. .__ F3the�'S,pectfy' � .� P,�& � �'i",�{'+�" *� cx-•>"�`" `,
APPLICAT)ION-TO-CbNF�� REPAIR,RENOVATE OR ttEMOLISA A ONE MO, FAMILY DWELLING
SECTION'1 -SITE IN FORMATION'
This section to be completed=byoffice
1.1 Property Address:
Flo t'e-A t:..e Zane Overlay D�stnct
Elm St District GB D�stnct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
IF0,-_4:& LL,¢ t2K /° 0
Name(Print) Current Mailing Address:
iC7 Telephone
Signature
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 goo (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
11 1 Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Secffow For Official Use Only
Date
Building Permit Number issued:
Signature:
i
Building Commissionerllnspectorof Buildings- Date
21 NORTH MAPLE ST BP-2005-0444
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C 219 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildim DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0444
Project# JS-2005-0591
Est.Cost: $800.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Roger Clark 021310
Lot Size(sg.ft.): 11151.36 Owner: CLARK ROGER P
Zoning: GB Applicant. Roger Clark
AT.- 21 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
P O Box 34 (413) 584-1170
LEEDSMA01053 ISSUED ON:10118104 0:00:00
TO PERFORM THE FOLLOWING WORK:SHINGLEI 12 OF ROOF OVER 1 LAYER
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 10/18/04 0:00:00 4922 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo