17A-051 (3) �SttAA1P�0 � .
Gzty of Nart4amptan
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DEPARTMENT OF BUILDING INSPECTIONS /=
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INSPECTOR 212 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 1083.4 to
act a iris/her construction sups:.,,i 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/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
f,� - P.
i �A& ) —, understand the above.
(Home owner/resident'sQignature 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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1)EP1it21'1`iElTI' Of' LUILBII�G INSPECTIONS
212 Main Street ' Municipal Building
'o
Northatnl)ton, Afass. 01060
NNIORTCER'S C011 TENT SATION iNSURANC�±. /SMAVI.T
%with a principal place. of busir ss/re:idene_
do 11cl-cby CcrilI)'. uIlac! t11c' 1)2ii1S 3ii7 OCil?itl S Chi nC.f]llI}', t11i?:.
I ?nl aII CIIlplO� 'Ci prOV'd'nj t11C i0110`,:'iI1L '':Ori;CrS COII9pC;1SaU01] COVCI'L: C �Or Ind'
calplovecs working on this job:
(InsuanG Corar�ny) e c,1�tu ntxr) ---- (`r�.�.ir,:i^n Date)
I ant a sole prod:ietor, =.enerai Of _(3meC w= ( cle One) and 11a`re hired
the contradLors 11Stet, beiov-r ,'i10 i? the i0 1 a^,% tizf Orf;PFS
-�
(T?nme�of C�tractG�)T
(Name of Contrcto:) _ 11ISUr,_rce Co �a �'(Pe!ic; trntrr) (1 ` r lion Date)
(Name of Contractor) — Jnsa--Mcti Corsi-my/?olic: Nuis)1._r) - =z-=1107. Date)
- (Name of Cont-actor) --- (Irs.r�nc� Cetnr_Iti;PoLic✓ Number*) (F:;:r-i ::ties.. Dare)
nil <..._fir::•.i
i
l zuII c, sole p1-OpI1cLUi <:I1'd 11�iVC, i10 onc, , 'i;:l;lii` for iii C..
1 am a home ov','IIc i)cI: 'II11Il ail
NO-I-Ii:plcasc be aw2st Ilia-
riot uxxt:tlu.0 throo unite in til dt he l:r.y� ,tz rc: s or o;
--I to un�c ttr tvc:f:n'_a;. ^n qtr; GI,!52-s! 51;,nr,.iic:.:ic::?y s hotnco,%-xr`cr a licc_,c a
ltg�l ctaiuc of an amPIO)w under thn Wcvl:cic Coe Yra.iion!.cL
I undc.-Tta d tfzit a omy of thv, ctatc::x1—y bo foru-nrcia:i to 11r=IYtwrtz�rrt:of Ir>dzu!riJ M.�l Y�'Ci cw of for tix
oovcust vcrificatioo and that f_iltuc to to c coy r M ur3::c,:7-,iM 25A of?,IGI,152 ctn Ic--d to the unrsasiiion .-C n-min.-J pc aL':a
comisting of a,fu)-of up to S 1-S00-00 x i^ tri r._e: of 1:p to nr..)-`r e:-.I avil xrulticl in'—C f<,ctrt of a Str,,`;v c i.<} t:-.d
Lrm oC'IDO.Do a day i r.ina mc.
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Pcrrnit NIIIIAXT x - -----------____--
SCT�ON 8 CONSTRUCTION SERVICI=S
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Re er ome m r,' uemeri Con racto =; Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION if0 1NORKERS' COMPENSATION INSURANCEtAFFIDAVIT(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...... ❑
W, Won
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 acccptable 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 frotn time to time,during and upon
completion of the work for which this permit is issued.
Also be advised that with:eference 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 Zon' Laws and State of Massachusetts General Laws Annotated.
omeowner Signature 0,41, rr✓
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SEC't10N a: S R PT,10N OF P, OPOSED WORK check all a livable r, s
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ j ecks [ ) Siding[ ] Other [ )
LW I
Brief Description of Proposed Work: �' � �r toC�c-D r
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll D• Sheet 0
fib= ewI,ou d.o edittorPT6 ezrstinghousing co;rnp-& th'&ollow�ng:
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 Nc
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
EC ON �Ol►fIN R AUTNORIZAT N!.
TO BE COMPLETED WHEN
OWNEFS AA EN7 �2 CONTRACTOR APPLIES,'FOR BllILE) 0 PEft{VI1'f
I, as Owner of the subject property
hereby authorize to ac; or
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I, 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 N e
z '7' el 9-
Signature 6Own� Ag ent bate
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 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT 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 properly?YES
No
IF YES, describe size, type and location:
M
T
City of Northampton
Building Department rt
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIRlR OVATE OR DEMOLIS4 ONE OR TWO FAMILY DWELLING
a
SECTION 1-SITE`INFORMATION .
con�pl eted by'office-
1.1 Property Address: T
�Lo l't C�-�,1 C.� Zo�ide�� � :�DverlaY Distract
SECTION 2 PROPERTYOWNERSHIP/AUTHORIZED.AGENT
2.1 Owner of Record,
Name(Print) Current Mailing Address:
5'&6 •-2-7z 5-
e Telephone
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,Oraly
completed by ermit applicant
1. Building /� (a)"Building Permit Fee'
2. Electrical 5� (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-On'1
Building Permit Number: Date Issued:
Signature:
Building,Commissioner/Inspector of Buildings Date
123 BRIDGE RD BP-2004-0780
GIs#: COMMONWEALTH OF MASSACHUSETTS
Ma :Block: 17A-051 CITY OF NORTHAMPTON
Lot: -001
Permit: Buildina
Category: BUILDING PERMIT
Permit# BP-2004-0780
Project# JS-2004-1152
Est. Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10018.80 Owner: PENCZAR WALTER A&DONNA J
Zoning: URB Applicant: PENCZAR WALTER A & DONNA J
AT. 123 BRIDGE RD
Applicant Address: Phone: Insurance:
123 BRIDGE RD
FLORENCEMA01062 ISSUED ON:213104 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 Occupancy Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 2/3/04 0:00:00 782 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo