17C-121 (2) V51 , DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '
Nortbmnpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as i;is/her construction sup(,: , ior. 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 project until such time as the proper permits and inspections are
made
I, c 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_ 9 1 71 b
Address of work ) �2
location �/L/
0"A Le MA b v�
DEPARTMENT OP BUILDING INSPPCrfol.'S
212 Alain Strcct ATunicipal Building
Northampton, A4ass. O1O60
W O RICER'S C O n/EP EN S A'T'IO N LEIS URA-N CE A FFM A VII
(I;cc-o.s�JperYnl tttx)
vrith a principal place of busines:Jresidence at:
(phone-')
(sn-�tici ty/stair.Ia p)
do hereby certifjr, under tic.pains and penalties of pegury.; :hat
( ) I am an employer providing dic following workCIr 5 cornocas-n:Jo, coverage for my
employces worling on taus job:
(L=Lranc� Comrac.) (Pclic:NL-nir_r) -- (T=pircior, Dzz~)
O I am a sole proprietor, geoeral contractor or homeow-cer (c cie one) and have hired
the conn-a(nors listed below wbo have the 'oUotvirlQ worke>'s raLpen_tanon pokies,
([1amc of COninaor) (InRranc; Compal)'/POUCi N'U.MLC:) (EX:)II-woo-? Datc)
-- (Name of Contractor) (tn.7arancc Comoaa)'fPoUcr Num6cr) (—L:.%Du-,6On Date)
(Name of Connacior) (Lnsuraacc Compan)•/PoUq- Ntunber) (Expi zdao Daic)
(Name of Contractor) (Lasuraac-- Comrany/Policy Number) (Expiration Datc).
(aQSCr]=d-,icocal rxcl'ifnco—.-Y to incud;iarwM.Cioa percn'aiac to.11
{ ) I am a sole proprietor and bave no one worl>3ng for me.
I am.a home owucr performing all the work myself.
NOTE:plc be aw-zm is—v jz;jk hcmco.�m,,,wtio caplay p=urw w do o, ao c rcaau work os t d%,cJL-;of
oac moce thm trio:tmr,.t in«-bicb the bomoo+wcr r=ich or oa the oun,c'a agpu n,-a=them z r ox Ca:I=--UY oec.d=-Ud m be
.avloyea unc e the kakdz xzpc="Lioo Act(GLI 52-=I(5)),:wGc
Boa by a homoow-=fcr c Iic-. v.or pc rm;z m:y c Idmoc LL-
11-PI n of ea eaPloyor uadar dh Woricola Compamatioa All-
[uada-rr-aad tact x copy of thin car®,ow ouy be fof-xard.d to the Dcp r<mm=of laduuil Accd..fj C>Moo of 4 for t6.
covcrto.-c t^a C='oo and ttu L'i/lyta��c w s�uc trovcrabt=Zcr zo�Yioo 25A of),(GL 152 ca Ictd to the=90aiioa of aimiasl prn-ltio
oo=Lrzin of a fine of up to s l JW.00 and/or oCup to ooe year cad Civil pmatie in tk fora of a Stop Work Ord=and a
rtn,0(::100.00 c d_y tpiaa me
Fx dcp.tm=il u,c only
Pcrmlt NttIDbcl
✓/ ,r9" .- �� h.(�p:: Lot
St�n.ZLllrt o Li�ccJpctzniUcc ��e -- .�
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
w ;
s -,
9�Reitsteted Homemprorrei�ent. ob"t` cfar - 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...... IJ
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,St to and Local Zo ' g Laws and State of Massachusetts General Laws Annotated.
•a Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition Q Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[C3j Other[
Brief Description of Proposed
Work: RZn / r 1
Utz r/Wo-X
Alteration of existing bedroom Yes��No Adding new bedroom Yes 1�1'— No -
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a Cf flew �i ase a t o a ro a;ez s Enc fioirs c�co efw r .6
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--OWNER;AUTHORIZaiTION:-TO BE.COMPLETEE3 WHEN
OWNERS 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.
Print me
to
Signature of O eogent ate
,
Section 4. ZONING All Information 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
(volume&Location)
A. Has a Special Perm it/Vahunoe/Findi ever been issued for/on the site?
�� �, ��
NO �� DON'T KNOW ��^ YES �~�
IF YES, dote issund: /
IF YES: Was the permit rdod at the of Deeds?
'
NO 0
IF YES: enter Book Page and/or Documant#(
B. Does the site contain a brook, body of water orwetlands? NO DON'T KNOW 0 YES 0
IF YES, has u permit been or need to be obtained from the Conservation Commission?
Needs tmbeobtained �-� Obtained v�� Oatm �sued'
^�� �_� ' .
C. Do any signs exist on the property? Y[S ��� NO
|F YES, describe size, type and location: '
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 8^�>
IF YES, describe size, type and location: /
/
E Will the construction activity disturb(clearing,grading'excavation,
�
on.orhUing>ovor1aueoris it part o�o common plan
that will disturb over 1acre? YES NO
0
IF YES,then a Northampton Storm Water Management Permit from the DPW ia required.
of Northampton Status pf �
Department
1 _. --"" ` ! , ;Main Streetee
�,I oom 100 ate atia :
N*4orthAton, MA 01060st
phone 413-�87-1 40 Fax 413-587-1272
1J '
l API�EjGAT10N T+ CO#STRTICT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 9I--SITEINFORMATION
'Ghis.sectton to be compietecf byroffice
1.1 Property Address: rr ju
Maps Cot nit
DL-0
Zone Ove�Fa}rDrstcrct '
»E�Sf Distcic CIIist�rct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record-
i c G G.��lc, 1.�fiGr�t;S qy
Name rint) Current Mailing Address r 7 q,;L4
L� Telephone ``tt
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 U (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) Check Number This Section For Official Use Only
Building Permit Number. Issued:
Signature:
Building Comm issionerllnspectorof Buildings Date
44 SHEFFIELD LANE BP-2007-0263
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C- 121 CITY OF NORTHAMPTON
Lot:-001
Permit: BuiLdiQg
Category: BUILDING PERMIT
Permit# BP-2007-0263
Project# JS-2007-000399
Est.Cost: $3260.00
Fee: $25.0 0 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groul7: np Owner: as Contractor
i.of c z t go ft.! iC 507.04 �. caner: WT!'TNTA C?-1AA[lT)P&.PAN4FT!a_W
Zoninm: URB Applicant: WICINAS DAVID P & PAMELA W
AT. 44 SHEFFIELD LANE
Applicant Address: Phone: Insurance:
44 SHEFFIELD LN (413) 587-0426 0
FLORENCEMA01062 ISSUED ON.911112006 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE 9 FT OF CHIMNEY
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:
Final: Smoke: Final: 0/<
THIS PERMIT MAY BE REVOKED BY THE CIT OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGUL ONS. -'
Certificate of Occupancy �Sigynaturc:
FeeType Date Paid: Amount:
Building 9/11/2006 0:00:00 $25.001082
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo