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Llify of Nortl1alupton -
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n" DEPARTMENT OF BUILDIi\TG INSPECTIONS ;
INSPECTOR 212 Main Street ! Municipal Building
S`
Northvnplon, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as Lis/her construction sup,-_i ,- sor. i lie state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or tivo 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 buildin! inspection (before work is
concealed), insulation inspection (if required) and a final buildiniz 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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5 m DEPART1.1EN-Y OP L;UILDI�'\'G INSPECTIONS
212 Main Street ' Municipal Builtlinr
Northampton, Mass. 01060
NVOR-KER'S COMPENSATION INSURANCE AFFMA IT
(1icclLSCC/lcrmittce) �
Nvith a principal place of businessJresidence aat:
i
do hereby cCIL1?�'', 111]C'el ill?: 71)31I1S iIMG pC:ilaltleS Of Del�lljy, tll2'
O I aln an employer providin- the iollowint, ',vol compo'ns<:11011 cove"I'; "tor InY
eluployccs woilmig on t?us job:
--- — —
(Ius=lc: Corn any) (Polio;Number) x-Q, den Datc)
O i aril a sole proulic or, ,,eneral contractor or homeowner (circle one) and live I lTed
the contractors listed b( loOw %vllo have the fo11o',v,_nc,, workers c-omt�en :ion policies:
(1 mC
of( ORCr Cior) (lI1SL'I I1C Colrmal,Pollcy Numt.`)-- -i;i:?::i::i1C1On DatC)-
(NlamC Of C011[r?C"Of) (Insu mica Compa:lv/1Iohc), Nuila;':!) �;?.Cl":iilOIl Dail')
(Name of Contractor) (Insuranc-- Compamv/policy Nuinl•�r) ~x,::raiio Datc)
-- -------------------
(-N'alue of Contractor) (Insurancz: Comr,ny/Policy Numb-:r) Date)
(atiadt:d-_'iti«Ial strct•!r.a�csar:e;ia_.lxic c::c4u:a:iec:patn�rr�t:;ell c_<:����rr•)
i
i i inn a so!c };ropnetor a.nd have no one .vor4 ir1 for me-
?ill l? home 1)erlor1111n- all the v,,c): iilvsl=If
NO'Il;:plc-ac be n�+uc Ilia;�ti iic fx<,:o.t1r_ra�+�cnplay�-:i::s w c.�c_•irt�aac�c-.°-r,�,:Y�cr: ,?air� ,i?;cu_�«cl!a:.:c.'
not axYC th a t1 too t:ai i ir,u�:i 11 ie la,a»tisz�reatt_�oc aI tlu_ kv zprurtcr nt L cdo c:r rxt�c rralil'cc :d_:.a t
cmpfo}mss ul cr t}r_rat, rt's cc y:—:a!im:t. (GL152,"1(5)).r_ 'I:�_t ai by e ho,,mw r1:`cr e Liz_x rc
Iegil aztua of an�Iploycc under tLo Wo,k; ,,Coiv;wrs:.ticn A-t_
I undo.-stand that a Cm of tll ctatczi:c If ruy bo fo{—tu J&d to tbo DctwlLnazi of Il utri�l Ac�ilcntf Offio of 11: uur-a for Ut
oova-ase Va_IGCllioo and that failure to!%care mvetn9-o tutder seetien 25A of NIGI,152 can Icad to Ux intpmition of C-,LMI:_l pcnaD;Cs
000nistmg of a fine of up to S 1,500.00 an—A,or ircprixxMVIctE of up to on-yt-r e�i civil pcnallics in dx form of n Str,)W(A<h < arA a
fiat Of 5100.0(7 a day
- ,utnr tar utc c�:y---._.-----------
-- PCTIIIlt NIllIltX=T
;� r Pll1t11LC Of 1 I(,�n',C:�hCrlll lft C.'; _ �-1 F
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 17 zn
License Number
Address ry Expiration Date
`
Sin ture Telephone
�Regste a '� bme mpvem"entContracto • „?� 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...... ❑
ii
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)
J g )
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 d Local Zoning Laws and S e of Massachusetts General Laws Annotated.
s
Homeowner Signature
SECTION'S M9CRIPTION Obi ROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedrooz Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll❑ - Sheet❑
6If�Ne"whouse "door a°dd'ition:.to ezistmg- h'o%�sing ,corrpletetheRfolLow-ing;
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 DOWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENTOR'CONTRACTOR APPLIES FOR BUILDING'PERMIT
r
as Owner of the subject property
hereby authorize � to act on
my ben f, in all matters r I tiv to work authorizeT d by this building permit application.
Stenature of Owner Date
I, Wit' �d �"cam as Owner/Authorized Agent
hereby decla pd'belief.the statements and information on the foregoing application are true and accurate, to the best of my
knowledge a
Signed under the pains and penalties of perjury.
;Print Na nat a of Owner/Agent Date
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
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
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 DON'T 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
IFNES, describe size, type and location:
City of Northampton Satus ;; Per "
Building Department Ccrrbt7� _ a^
212 Main Street SewerlSep r a . "
Room 100 INa er/IMe I v
Northampton, MA 01060 TvvoSetsq
phone 413-587-1240 Fax 413-587-1272 Piet/,Site
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: This section to be,-completed by office,
I
Map . Cot Unit
Zone Overlay District
—�T
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Own r of Record:
Name (Print) Curren Mai ing A re ss:
Sig ature
2.2 Authorized Agent:
Name( int) Current Mailing Address:
Sig tore Telephone
S TION 3 - ESTIMATED CONSTRUCTION-COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2 Elecrical (b) :-- timated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4 Mechanical (HVAC)
5. Fire Protection
6. Total = 0 + 2 + 3 + 4 + 5) Check Number
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: ------ ----- —
Building Commissioner/Inspector of Buildings Date
BP-2003-0811
GIS#: COMMONWEALTH OF MASSACHUSETTS
x"jiwwwwyd CITY OF NORTHAMPTON
Lot: -001
Permit: Quildin
Category BUILDING PERMIT
Permit# BP-2003-0811
Project# JS-2003-1329
Est. Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: James Roberts 117154
Lot Size(sg.ft.): 26832.96 Owner: DUPES DONALD M&HELEN C
Zoning:URB Applicant: James Roberts
AT: 91 HIGH ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON.412103 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 Occupangy Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 4/2/03 0:00:00 742 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo