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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR
212 Main Street * MmiiciPal Building
Noi-thainpton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as 1.1s/her construction sul ;nor. Tfic stave 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 rouj4h buildinp, 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
s
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1 TPARTMENT ON RUIt AVIV INSPOM IONS
2]2 \lair, Street ' Municipal BuiWiq,
Nortitatnpton, Hass. 01060
�4'ORICI�R'S COMPENSATION INSURANCY, !kFVII_DANTI'
Nvith a principal place of bwEesWeNence
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I aln a SOIC; 100P iCYI pow?! , ,i .?6 eo"-'nc: (Ch01C on" )
the contractors Wed Mow t V -'h v;(>;ke t COMPOns?: nn phmes
R`nme of Conwan5a
(name 01 Contnl.tol) ;lll,lllala t�ni: t.?iilit�t�� �r CV'LII?�'r'_f� A;:', ....__
(Name of C,ot,umaco
1 mil a JUIC ,.ill fl3'.',_ no Olii •.'1;.... l0i :11
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ncx axicc th>l thrco units c;a{�r't Lx i._....;•.�:,:mow c,w t...- n t C'tn'-r:11.'
legal etztut of an c:��lo}'a urt�'.�r l.`.:o Wcv1cY'e t��;i;;rar...tioct Act
I undcntand Tea cmy of Lhu ctitc:::.z.r:ay F j��to.l to tln[Yt*u tcx«t of In�tut:id Ati�ra�t a'Oflicw of I::au..�.a for L.c
oovcsagc vr.-ifi�tic,o azd that C_ilurc to ss.!a cu�tra�ut;3cr sc�.ion 2SA cif?,1Ci1,1 S2 can IcaA to Qxi in,�ozilion ufm�ni:_1 fralt_a
coaluting of a fine of up to S I SN TOO n:�-i'�x in:,ri_rrv�.-�1 oCup to cr, }`a nti1 civil!xrultia ml,fc-on of n S'.c;>"VcA 02 v t7'1 s
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SECTION 8'-,CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : i1% �6`-' �6(11
License Number
Address Expira ion Da e
Signature Telephone
sip, Not Applicable
�9 -Regt`steted,RVE M-R&emerit Cont actor El
Company Name Registration Number
Address � /n � Expiration D e
cc, �� / 6 r U� v�l Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted v ith this application. Failure to provide this affidavit
will result in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... No.. ... ❑
00
11. orne ®EwneD la,
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 fe-which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 1533 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
SECTION 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing "
Or Doors ❑ /
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: �r? �� oa,= G�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll O • Sheet ❑
sa:If"New house antl`or'`addition`tO existing tiousin7, c6mp1et6Ahe.fo11owin14;
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
SECTION 7a -OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I Z/� cc Ix—,, `� _ , as Owner of the subject property
hereby authorize r to ac; or
��r � -�� ����
my behalf all matters relative to work authorized by this building permit app!icatlon.
ignature of Owner Date
ft I`k— �' �/! _ as Owner/ uthor Agetrt
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 ame
Signature of Owner Agen Date _
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 DON'T KNOW _ YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book _ _ Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 property ?YES
No
IF-YES, describe size, type and location:
� M
City of Northampton Satusof P'
Building Department
"' - 212 Main Street SeeWW�lSep to alb _
Room 100 Wa�rlWet va a (ll,,
�orthampton, MA 01060 Tito SetsolStr'C M Pa s RNSIM11,
003s
u
p�hAJ 3-587-1240 Fax 413-587-1272 P'lo/SttePlans;
Qther�Speclfy
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APPLICATION TO CONSTRUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be,compieted by office
1.1 Property Address: E
Map Lot Unit
Zone Overlay District
Elm St.District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:.]
Name(Print) Cur;ent Mailing Address;
_ -- -- Telephone
Signature
2.2 Authorized Agent:
Name(Pri ) Current Mailing Address: ?
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit a licant
1. Building 5 (a) Building Permit Fee
,i i
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: Date Issued:
Signature: _
Building Commissioner/Inspector of Buildings Date
BP-2003-0890
G1S#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0890
Project# JS-2003-1432
Est. Cost: $1153.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DE Sheppard Roofing 105885
Lot Size(sa. ft.): 0.00 Owner: ARNOLD RUTH B&
Zoning URB Applicant: DE Sheppard Roofing
AT. 162 PROSPECT AVE
Applicant Address: Phone: Insurance:
224 BERKSHIRE TRAIL (413) 587-0092 O
CUMMINGTONMA01026 ISSUED ON:4122103 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 Sienature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 4/22/03 0:00:00 836 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo