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DEPARTMENT OF BUILDDITG INSPECTIONS /=
INSPECTOR
2212 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 has/her construction sups:,• sor. The state defines"Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one"dr ti+oamz y _-
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 YLfiR ing department for the City of Northampton wants-any person(s)-who-seek-t-o
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/footines(before backfill),
sonotube holes (before pour), a rough buildinE 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-tome.
Date
Address of work
location
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DEP/tRTMEI-rr OP BUILDr,G INSPPCT70t.'S -
212 plain Strcct ' Nfunicipal Building
Northampton, ATass. 01000
WO RICClt'S C O NIP E,NS ATZO.N 13' S UTZA-N CE A A V-1-I'
(li ccas.,xJpermi ttcc)
,%IlLb a principal place of businessfresidence at: -- --
(stmt/ci t}/stztc.rri p)
do hereby terrify, under thc.p?JM and penalties of pcgury, h11
j ( ) I am an employer providing the following «orkc>'s comocasaDo covervgc 'or Illy
etuployces Nvorlong on this job:
(Lsur�c Conp ) (Polio:Nu--.Lb--r) _ :•pir`rioc Dom)
( ) I am a sole proprictor, general contractor or homeowner (cc:e one) and have hired
the contractors used below wbo have the fokwiog worker's compen_tnon policies
i
(i`+HIRc Of Conincior) (IRSUrancz CoinoaSi)'t•PGUc-{ (F�:7)1s1:?on D11c)
(N—c of Cootrzczor) (Instilrzn CAIIIDai1)vPo!icy Ntunc_r) (xDirtion Dale)
(Name of Co=da,) (Insu.rance Compan)-/Pot;cy Namb:r) (E-xpirdoa Daic)
(Name of Contractor) Clnsuruc: Coinzauy/Policy Number) tttpitation Dare).
__
(ntvc _d3icoczl�ccx,ifncc�z_�to i W--IVI-inF0r=-:•ioc pcuninias a.1t ooQ-_moo a)
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a sole pFopnetor and have no one work-ing for me.
( ) I am.-a home owner performing all the work myself.
NOTE:pl=.=be ca-Art rt,•.v }a bc�a.am v{zp cloy per om to do - -• cr=oo c rip•+-orz as z d%,<n-Z of
1 @Oft th n t L�1fJ 3II �t1X bomao wet r c ida or oc db.(To�s=7(� }�tb�Ca LT aac('^_I,try ODC=cLrLd b+
employ=uaCc the..ter efz won Act(GLi152=1(5)).Lppri=S a by a bom.--a for a li ^Y or pewit r✓y evid=xc tbo
lei l cl t>c of en =ployec under dte Wok-e-Cooapoaszyio Aer_
I uadc-y.ad ihet a Dopy of tbu mtemca may bo foewnrd.d to ebo pcpa.nmrn¢or Inau,s e(Ae�idezII�'Oboe or I,�for th.
cOv�Y cif mioo and ahe.t Liltzc to sa==cavcrase tizodc==oa 25 A or 1.IGL 152 cw ltd to the impasIIica of c imia%l pca%$ia
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SECTION 8-CONSTRUCTION SERVICES f `
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone _
Not Applicable ❑
�,l�ii1/d c�'c-U GC��r L�• /4 'z�QC/!.�
Corn anv'lg a Registration um er ----
Address Expiar ion Date
Telephone �1�7C%�---
SECTION 10-WORKERS'COMPENSATION INSURANCE:iIFFIDAVfT(M.G:L:c.152,9125C(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 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"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.applicablel
New House ❑ Addition ❑:. Replacemert Windows Alteration(s) ❑ Roofing ❑
Or Doors 1K,
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0] Other[d]
Brief Description of Proposed S
Work: Y4��-1f1i,4-yL ojtK_4�e,LV -
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sane ose � a cI camexlsinciouslng�carriplee#la a o >rq:
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
L 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-OWNERAUTHORIZATION-70 BE COMPLETED WHEN
OWNERS AGENTAR
R., PLIES FOR:BUILDtNG`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
G �, ��r'f� ,as Owne Authorized
ent ereby declare that the statements and information on the foregoing application are true and accurate,to the best of m Authorized
an a ief.
Signed under the pains and penalties of perjury.
�CG l�1 td.i �G► r��LI
Print Name
ure of 0 rl Date
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 i !
Side L:' [ R: L: R: --
---
Rear
Building Height
Bldg. Square Footage % t (-
Open Space Footage �_� % ,
(Lot area minus bldg&paved
arkin
#of Parking Spaces �^
Fill: }
(volume,&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 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
IF YES: enter Book I Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 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 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 r NO 0
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
,City 61 Northampton s
,',Building Department
212 Main Street
Room 100
Northampton; MA 01060 t'
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION1 -SITE,INFORMATION
Thissection to be coropteted byffice
1.1 Property Address: a "
�.�. . n... � �* �f� ;�; „.•. "Utah>
OvertayP►str"at
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SECTION 2=PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Reword:
�3 �f-� �� V t..t� ra � /UU• ��1DL�Sf /���,•rr_�c^—�'_
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agerit/:^ /
��ril L..E3 t".�t?i l l 5 Ca d i!'11 csC,fc �i L �r..�.� 1�9r'! C7tC►S"�
Name(Print) Current Mailing Address:
ig ure Telephone
SECTION 3 ;ESTIMATED"CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)$wilding 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) / 47, Check Number
Thin Section°For Official Us
Building Permit Number Dswed:
Signature: !
Building Commissioner/inspector of Buildings Date
63 NORTH MAPLE ST BP-2006-0272
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 127 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0272
Project# JS-2006-0393
Est.Cost: $4174.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sa. ft.): 11194.92 Owner: KULIG JOSEPH&SUSAN L
Zoning:URB Applicant: John Corbett
AT. 63 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON.911312005 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:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy si nature:
FeeType: Date Paid: Amount:
Building 9/13/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo