17C-140 (3) City of Warthampton z =
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building 5
Northwnpton, MA 01060 ,
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNM 108.3.4 to
act as 1 is/her construction supc: , sor. T he 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 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 rouzh 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.
Daze
Address of work
location
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A f �iasaYtchrtrc11a —
w DEPARTNIE74T OP DUIL00\10 INSPECTIOI.'S
212 Main Strcet Municipal Building
Northampton, Mass. 01060
WOR CER'S CONIPENSATTON MSUR CE AllFIDAVIT
(7i cCnsxlperu�i ticc)
with a principal place of businessiresidence at: -- -- -
7 A 1L S" (phone;')
( c1 t}/suJt�rip)
do hereby cerdi ;, under the pa-ins ai3d penalties of penury, --hai
( ) I am an employer providing the followint'workcr-s cotrlocns_�o, cove age for my
emplovees worUng on this job:
i
Omura c= Conraay) -- (Pcbc-,Nu-mi^r_r) ----- (—E;-pir<tior, Dzte.)
O I am<�Ole propl-teto general contractor or homeowner(ci cie one) aDd have hued
the cooi -acior5 lIS-te e ow wbo hive the folio%vino worker's camper sa6on policies:
(111am-, Oi Coat:acro:) (InRlrancc. CoInparl)YPobci ?,,tu-mh--) (E :plr-JuQn bate)
(Name of Coatraaor) (lnsurznec Comoa.ntivPokv Ntuncr-r) (-E»irtion Dale)
(Name of Conn-aclo,) (IIlS1i-acc:. C'.omT=y1PQUq- Nambu) (Expiradoo Date)
(Name of Contractor) (Insurance Company/Policy Number) (-cpi-,ioo Datc).
(aII�Ch k" oc5.1 chcct,dnocc r••to 4V-U<�c iafocmi'ioo pctn_tn=G to aJ.l
t r) I am a sole proprietor and have no one wor-Ling for me.
( ) I am.a home owner performing all the work myself.
NOTE:pt=c be eww,t+,.w2r.]c bemco.�ncrs v,o csplay peraas to do -;, ��-.—,a c r pair work on a dt r1L--,of
aot acct th=a Lb—tails is-�ch the bomoowoer r-c=&=oc oc the gmuacis p7v rtes -tbc-ro c.-c ooe oceed=-ni to be
cavloyes uoda the-M -c==Pc=_.,:oa qcz(Gl_!152,s 1(5)),=-pplia.000 by a bomeo%�a far a bc=_oc pcmw rt_y e��dm c tLe
Irga.l nten.,of as c=ployec uoda d,o Woc4c.or'a Compemal.ioa A&c-
I unde:txad that a Dopy of Chia eatcmoet m„y be f---,id to the Depot mm¢of In�+srial Aeadear� Offioe or 4a foe tb>
oovcf` c vcrif c=Iioa&ad t1u L-iltat to saauc lcovcrase tmdc soc doa 23 A or MoL 152 can Ic d to the j=por7600 of cr i pa-Wcs
coaziss of a fine of up to S 1 500.00 and/or imprisoc�of up to coc ycs ted ctil p=orno is do room or Stop Wort;Orde and a
(tip(S 100.00 itt me
F«d�.rtm=�u,c only
o Permit Number
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Sig=suzr of Liccnscc/Pc rm i ttcc e --
SECTION 8-CONSTRUCTION SERVICES r
8.1 Licensed Construction Su ervisor: C Not Applicable El
El Name of License Holder: G 4 IVI.�� c� -1 T
License Numberf
S1 Crucr c 3fS
Ad res !' Expiration Date
Signature Telephone
g-Re ts>ler Hom�rit rovemec ontracto Not Applicable ❑
Company Name Registration um er - -
ea
Address Expiration Date
Telephone �/�G b
SECTION 10-WORKERS"COMPENSATIOPl INSURANCE APOOAV(T(M:G;L.c."152,,§25C(6jj'
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"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 ❑ ReplacemerlMindows Alteration(s) Roofing
0r Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[0] Other[o]
Brief Dipgription,of Propged
Work: �n�l'+ iuc . o- t'k,lS�ti�a (� rliusi1 :rc ��E" inruGa�ir' �Ni u �aar 't
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa.ifs(�Cewuiraersexan'dct#iait,#ca..axis#iiico>t lsl�tg:`cac>r�gfet�r�h'e�f (r�u���el:
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-TO''BE COMPLETED WHEN
OWNERS AGENT OFt CONTRACTORpPPLIES.FOR'BUILDING=PERMIT
t t A; L;u4> as Owner of the subject
property
hereby authorize ��4 'QAK%,s rN�`�
to act on my behalf, in all matters relative to work authorized by this building permit application.
C`y C
Signature of QvVrer Date
f
I C LAS �rVVL s I-C4 _ ,as Own /Authorized
Agent ereby declare that t e statements and information on the foregoing application are true and accurate,to the best my knowledge
and belief.
Signed under the pains and penalties of perjury. '
t me
S ature of Owner/Agent Date
A
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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
f '
Lot Size
Frontage
Setbacks Front �— ?
� � k
_ 7 r
Side L: R:! L: R:l _
r° I--- --
Rear
Building Height i --! -'-
Bldg.Square Footage f-- ? I %
Open Space Footage € % -a
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume'&Location)
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A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
N0 0 DONT KNOW 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 - DONT KNOW 0 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 0 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 Q
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 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Norti ampton
Building Department ; '
s _
212 Main Street
Room 100
Northampton; MA 01060etsfl Strotar
phone 413-587-1240 Fax 413-587-1272 PlatS� ians� _
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION I-SITE INFORMATION
n, Thcs section to be completed by office
1.1 Property Address:
Maw Lot Un+t
Tone � � Overlay Dcsfrcct '.
' 5
!Y'�f
? -pit let. ....
SECTION:2-PROPERTY'OWNERSHIP/AUTHORIZES AGENT w
2.1 Owner of Record:
Name(Prin) Current Mailing Address:
(F z'4'e z Telephone
Signature
2.2 uthorized A ent:
Name Pri t� Current Mailing Address:
Signature Telephone
SECTION3-ES TIMATED CONSTRUCTION COSTS
Item ~ Estimated Cost(Dollars)to be Official Use Only
com leted 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) � O C�J Check Number
' This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
46 NORTH MAPLE ST BP-2005-0532
GIs#: COMMONWEALTH OF MASSACHUSETTS
MW:Block: 17C- 140 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateeor . BUILDING PERMIT
Permit# BP-2005-0532
Project# JS-2005-0698
Est. Cost: $2200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: BAYSTATE WINDOW & DOOR 125626
Lot size(sq.ft.): 9931.68 Owner: ALTWARG AMY S&
Zoning URB Applicant: BAYSTATE WINDOW & DOOR
, ?1 - q N pTH '" API E
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Applicant Address: Phone: Insurance:
87 SHATTUCK RD (413) 549-6824
HADLEYMA01035 ISSUED ON:10129104 0:00.00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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: 0 k A{ !f-O ✓
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS
Certificate of Occu an Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 10/29/04 0:00:00 225 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo