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DEPARTMENT OF BUILDDTG INSPECTIONS
INSPECTOR
'212 Main Street • Muuic;ilal Building
NortliinPton, MA 01060 .
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNIR 108.3.4 to
act as his/her construction sup,.::,isor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,a one or two fame _
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 Wil tng departmerit 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 fegulations. 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 AY the project until such time as the proper permits and inspections are
made
I, understand the above.
(;� owner/resident's signature requesting exemption)
I will ca 1 to schedule all required building inspections necessary for the building permit
--- - issued to me - - -
Date
Address of work.
location a V3 3a I'T5- PT
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DEPARTJVEI rT OF DUIL00\10 INSPECTIONS -
212 Alain Strcct Municipal Duilding
I Northampton, ATass_ 01060
WGRICCR'S COYQ'ENSATTO.N MSURANCE AF=r1.V11'
(IiccnsxJpermltt�)
%with a principal place of business residence at: --
ay� �I�G� FCe�� �e. j'il+l - 6l�'a (phone') �/(3 u°t/-/�3C
(Sarzvci ty/a=la P)
do hereby certify, under chc.paim acd penalties of perjury, hit
j ( ) I am an employer providing the following ivorkcr's comocasaoon covcr gc for im
employccs ivorlong on this job:
(L:sur�c CoQr ) (Policy Nuter) -- (r:-pirvvor. Dzi--)
O I am a sole proprietor, general cona-actor or omeowner cle one) and have hired
the
I tour actors listed below who have the foboviiuQ workees comoep—sa6on poces:
i
(-Namc Oi Con'=Ci07) ((n2ranc c Comoan}•iPauc-, N'U. h-c ) (HL)Iruuon Date)
(Name of Conc-aczor) (lnsarznc Comoany/Pone- \Unbcr) �i�ir�ion Die)
(Name of Coa aeto,) Gmsuraia Compan}•/Pout}• N;vrbcr) (E-Nairsaoo Date)
I
(Na me of ContracZar) (Insu=cc Compzzy/Poucy NumLticr) (Ea�irtion Daft).
(a>zsc:s.:t�:�ocil x.'cd.tl nccca_-r cn jr cU'C�r informi-ioa P=-I ns to.17
O I am-a -sole proprietor and have no one worioDg for me.
I ( I am.a home owacr performing all the work myself.
NOTE plese be aware(fi,. +W]C hem a.�acrs M()p==ply p,=-=to jJ ^^ cs csao a repair +-ark as a d-11ti �of
ant mote tea t sv zmits is-bioh the bcmoo+vvc maid=cc Oct the gounc4 zppu�tbe-ev LT DO(Ca.---Uy oc--:d.-ni to t+c
airplo)--s unee the k r=P -..-.Aa(GL157=1(5)),a WLica.tioa b-f a bomvovc!c c G c x peznn=y-ids ebc
Ic-yl Host o!--=Ploy-coder die Wor-e-C.oe�om.yioa Act_ '
I
I
I uDderLad th4 a copy of tbi, may be foc-,d.ed to th.a DcQaitszrsa of lnd+.sricl Acvde y OTI-of tsus.+asea ror th.
oo""Se`^eir� and the C_iltac to ioauc'eovrrnCo trade soetioa 21 A of}.ioL!52 m lr�to the i-�itioa of c;..,:,,.t pcnaltie
coal zu. on tW b S IS00.00 inditx�syo or up Lo ooc YL and c%il p=...ltia is tSc roan ort Stop Wort;Ord--and a
j
1=0(S I Q0.
/ For dcp.naa�'•t use only
Permit Numb-
1.-Lap..
i t3irc of Lie---= Pcnniuc= �Ce
SECTION 8-CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
�.:Re" sfeie�'Hoiti'elrn rove rite Not Applicable ❑
Company Name Registration Num er
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...... ❑
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 D )of the Massachusetts General Laws Annotated,you may be liable for person(s)
you hire to perform work for you and permit.
The undersigned"homeowner"ce fi d assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances,Stat al 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 ❑.; Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[I]] Other[CJ]
Brief Description o rcopSo ld G� �C �.rP2 (AYe�
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa_ff PteW �iasedi ad %atersicaies cticorpieftfa�E�awi,ra:
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? 11)0
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? /J19/ 6A5 Fireplaces or Woodstoves � _Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction 000:'
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 [4
k. Will building conform to the Building and Zoning regulations? Yes ',-�No.
I. Septic Tank City Sewer Private well City water Supply f
SECTION 7a-`OWNER AUTHORIZATION-TO BE COMPLETED.WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR.MALDWG.PERMIT
Jc�SC�'i`f w L7 /J� 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
J 05 e )7— LI11011id-q as Owner/Authorized
Agent hereby dec that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed u er t e pains and penalties of perjury.
v _ tj )N'A
Print Na
Signature of Ow gent Date
�
� ~
Section 4. ZONING All Informati6h Must Be Completed. Permit Can Be Denied Due To Incomplete Information
4 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 0/.
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume-&Location)
'
A. Has Special Pennit/Vahonuo/Fi been issued for/on the s�a?
' x�� »�4 �~� �
NO �� DON'T K�W �� YES ��
IF YES, date issued:,,
IF YES: Was the permit recorded at the of Deeds?
NO «���
� DON-r m"um/ .^"
IF YES: enter Bonk Page: and/or Document#:'
�� ��
B. Does the site contain a brook, body uf water orwetlands? NO ��/ DON7KNOVV �~� YES «��
|F YES, has a permit been or need tobe obtained from the Conservation Commioaion?
'
Needs tobeobta'oed v�� Obtained v�� Omte |usum��'
v�� x�� '
C. Do any signs exist onthe property? YES Q NO K )
IF Y[3' describe size, type and |uuudon: "-'Toe
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
'
IF YES, describe size, type and location:
E. Will the construction activity disturb grading tion,or filling)over 1 acre misdpart ofo common plan
thawU|distu,bmwr1uore? YES � ) NO
`�^
|F YES,then u Northampton Storm Water Management Permit from the DPW is required.
City of Nort0ampton
Building Department
212 Main Street e E
Room 100
F ^ij05 Northampton; MA 01060 . gts rr 'I
e `phone 413-587-1240 Fax 413-587-1272 PCatkSt n � `
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION,1 -SITE INFORMATION
TI)in sectron.to be complete byofiice �'
1.1 Property Address: _
Nlap Lot Unit
r'(.�QC'� /'114_ O10(JaZ Zone OverlayDtsfrECt
E[rti Sr District CB DWtildt
SECTION 2-PROPERTY'OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of R d:
9'13 F�0�•Jcc )W X P ��C9 j� 9
Name(PriA4 Current MV/n3Addrp� —f4�6
MV
/n3
Signat
2. thorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3.-ESTIMATED1 CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ,fJC- (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building,Permit Fee.
4. Mechanical(H AC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
i
Building,Commissioner/Inspector of Buildings Date
243 BRIDGE RD BP-2006-0271
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-062 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0271
Protect# JS-2006-0392
Est.Cost: $2000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin Homeowner as Contractor
Lot Size(sg.ft.): 30143.52 Owner: LAMANNA JANET L
Zoning.URB Applicant: LAMANNA JANET L
AT. 243 BRIDGE RD
Applicant Address: Phone: Insurance:
243 BRIDGE RD O 584-1636.b
FLORENCEMA01062 ISSUED ON.911312005 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 LAYER
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• 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