11C-022 (3) o¢/•StSAMP�o ��
C I�!lSSRC�IIS CttS e '
�^ �y DEPARTMENT OF BUILDD�ZG INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNlR 108.3.4 to
act as l is/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 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/footines (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
0YGv`J�
� .. a].rcil:15 c t17
DEPARTMENT OF BUILDr?�G INSPECTIONS �
212 Alain Street ' Municipal Bulldl ng
Northampton, Mass. 01060 '
WORKER'S COMPENSATION INSURANCE A z�.VI_T
%vltla r. principal place of bus"'ness/residenc
,//t7— 1 n ')
-1
CIO l CrCb}' CCrt1Ii`_ " <'` i
7 L.7 1 t}1C ") Ir!� 3iiu pC:il iL1C,; Chi pt";l�lii
..Ill an employer pi-Ovi ir,O" tle � -fcO119G.c1Mt]O11 GO e. .Q,c fc: L
tmp!oyees wo6drlg on this job:
�:r' �f_✓ /out. / �'v ' '�'a`J'i � 1'7Ii_Ur —0J
(Irs.L-aaG: Comm')
j I `cl a sole pronrie*_or, genera c-on e cr hon-:to,,-;Der IcLcle Oct) and 'tta.e dir(✓-;i
f.l1C comae m liste-' beiov ,t::q i1 t-t `Oil G10C: P S c0i DeII Oil C!I :cS:
of COrlL"l�:iv') �LRSnC:. C.C.S^:::.r'011c'r' r1 �r) ;�", .�..C-Date)
(Name of Contractor) - (ilISU arse Co _ v�Pc!ic; Nunes ;) (F>:o .,. o:Date)
(Name of Con-actor) tJ
_ atc-)
(Name of Contractor) -- (Ins rai ce Coinn �olicr N - (F; -::io-Date)
(..^.I�1G1�-jfJCC:1I S.:.Gt:....'_... — ::�:.:_.�.._..:'Y:':l:::i'i--._.... ..•.li^:(:-_-�i::-7
I "cull a solc proprle o ilii l ileavc 110 011C Io 1 :Il
.�
j
11I1 1? home cvvnc.'
NO-rF:picas be ftw:vc La>t:y�ilc Fcc-eo.y:r-:: :c r_ pt. ;r7—- cr::pait+
not utccc tEtu t lr=L"i's I. yyt dt she i r.-.�.:y; r=:,;=a-a: : U .:3 _._ i Lycc c o-.<eers:li c<r.:::_::-J:o tti
e.m,p10ye3 un.'.er the:Vert' :s ca=- t-1;rc-Act(GI,152.r_•!(5)),n,:, ._air::V, a ho iroa ur icr e Lc--u a p-r::i:::
Iegal ctatur of=ecployx under 4:n Woody iw^�;xr�Iicm l,cL
I u.-ydc_-:tend th ,a cmy oI thi.c:_t c s_e:iy to fixes :-irj to t!!:DYJ-L--d of lr,&L tri_I Ao:.r.—:f Oi 3c oC is r>?x fort x
covcnAsc Vail ction aad th_t —Iurm ur-'d--scCttc^_25A of MGL 152 car,ic_d to tlx irn{vzi _oCc�j _1 per l:a
court-Img oC a Ctrr_of up to 51-500-00 an.'.'nr i_:;:ri�;c-Z-,�.%nC;:p to cr.:}-::a:.i avi]ixr•zl!ic in�c fc;rrn cf a S!r.�
firm
or S 100.00 a C11 a7p,in:t rn- .
For dc,:uutxsesl u.c ally
�!��!.-c_r�•.� Permit Numtr:r _-----------
I
c-'3. mo)'
- I
��1�IIACll1l.' 17f:'1.iccn,:C':�1�Cfi tr.,_..._._ c
SECTION% CONSTRUCTION;SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 4;1"("'v)
License Number
If 7-0
Address Expiration Date
Telephone
1 0 W iry
Signature p
Registered= omezir►aro . menu-ontractor-' - ,� �..� - -�._.�R Not Applicable ❑
Company Name y� Registration Numb
Add,7rs Expiration Date
-Telephonel
SECTION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M:G.L. c. 152, § 25C(6))
Workers Compensation Insurance affida it must be completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance f the building permit.
Signed Affidavit Attached Yes....... No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinas 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
a
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SECTION'S DESGR(P.TION OF3PROPOSE6 WORK(check all applicable)
Eli 7
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roof' g ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Sidin
g J Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 • Sheet 0
6a I.fi'h7ew house. n -or additi`EA-0— xistin,a K0 §1ffRKom MTUI e-fol'l ffi:
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
SECTIOta1NN�R AUTHORIZATION TO BE COMPLETED 11VHEN
OlNNERS/GEN TORCONTR'ACTOR APPLIES FOR-BUILDING PERMIT
as Owner of the subject property
hereby authorize r:,} L-_ '�JU to act on
my bphalf,,in all matters relative to work authorized by t is building permit application.
Signature of. er Date
as' /Authorized Agent
hereby declare that the statements and information on th6 foregoing application are true and accurate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Prini U me
,�-�..1?�.-_._�-- �'"t�s,:..mo''`t"'? � ,� ;�'�`•-,°,
Signature of Q=w/Agent Date
t
De�arbnent use only ' K
� � r * sir
City of Northampton statusflf Permit
Building Department G&MI'.0 uew'�
212 Main Street sewer/SepAvabiijr�
�.�..,���°'c�'
Room 100 —Wdfez�ilpVell AvasfabHil t ° s
Northampton, MA 01060118
phone 413-587-1240 Fax 413-587-1272 �lo#setans: � � g=
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE-INFORMATION -7
1.1 Property Address:
This section to be completed by office -
+o��^ r° loll l _'ar` Maly Lot Un>t
Zone - Overlay Distract
„Elm St District " CB Distnct
SECTION;2-PROPERTY OWNERSHIP{AUTHORIZED AGENT
2.1 Owner of Record:
Name nt) Curre�Nailing Address q
r cLc'-'� f 'i
�- Telephone
Signature S 4 <ye 6
2.2 Authorized Agent:
fj + ! "! d t.f, rw"�Y`r d' jiy s`✓[ /i f' /s{J f' ' j�.f �_
F �•
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 '(a)"Building Permit Fee
a
2. Electrical (b)Esbmated;;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: 1�Z_ Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
7 HEFFERNAN ST BP-2005-0102
GIS#: COMMONWEALTH OF MASSACHUSETTS
t aixfflock: 1 IC-022 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0102
Project# JS-2005-0124
Est.Cost: $7695.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin Homeowner as Contractor
Lot Size(sq.111 8494.20 Owner: RUSSELL GEORGE J JR&KATHLEEN
Zoninp,:URA Applicant: RUSSELL GEORGE J JR & KATHLEEN
AT. 7 HEFFERNAN ST
Applicant Address: Phone: Insurance:
7 HEFFERNAN ST
LEEDSMA01053 ISSUED ON.7129104 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL SIDIING
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 7/29/04 0:00:00 19437 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo