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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '`o 5,0
Northampton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as l:is/her construction sup(,,-.,,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 perfo*n 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
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DEPARTMENT-h OI' LUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060 '
'`VORICER'S COMTENI SATION 1NSUIZANCE A- i iMANI-r
1,
(Iictirs°�'fcrrniltc^)
v"ith a principal place of busiress/r-s;ccnco
- ---- --—-- ---------- ---- - ----------- --— -(p h 0 T]c
do hCreby CCr'dfy} LIlacl' i1]C ?Ila pCi]a1t1C;; 0i pCrJlII'ti' illi!:: -
I a-m arl employer providing tilt iollo',ViP.0 ,,ol't_CT S Coml)c 1satloI] CUVCI2' C 'Ur trey
eltlployces working on this job:
(Insiran� Co>�pam) clic;N Linn ber) ---- (E��;r.tiea Date)
l j I aci a sole prool-ittor, genPrii conk or o- norLeowoer (Cucle Oct) and 't]ave !iUtd
the contractors LsteC beiow -,-,-ho i]- c L1 1c i n; ,:, � e -iii
] o lo.� orke s coLMp nsaton -es:
(I`Ime Of COn(IaCiG c: T-.
Coll .�r;:'Potic; N1usnh--T)
(Name of Cor ctor) 71 �r. r-ce Cow r,`/Po!ict' Nlnirr; Date)
----------
(NIame of Conncto; _ _.._--_--___ __ ---
�) (1rh;...,I1C: (_Oi;J Ii�O�;C. _-X; , i:C_ 1.%ate)
- (Name of Contactor) - (It]sllranc� COIr.- I�!Poli Nu.m�=*) (I;:ni-::ic. Dare)
(r.tiidt;-d'�itier.it z_:eei i':x.-c-z,r. •.n :e cfu'-:..:-.c:'u:i e;:=-'•-:..:..�. ei;c:<:ro::r:r')
l/l LTl c: UIC 1?rUj?r]CLUi iiil'1 i]t?V O OI]C ..'i;r
I Gill Z? 110I11c o',Vlle' iicr CIn1I1 iC. V: ii 1
i'r f.
NOT F:plc_sc be nt,'a:c[!a:.,i•:]c
not:recce t}l:n throe uuis ir:t,i dt he hr. .,Zr or a; ;:_>z ar cr�S LhcC.e c:t DX C=Yr2A."
ea,ployv—s urur t}.-«c;i:n'a ar •—:e!i^n,+r. c
i..•.t_, :c:;by a ho;t o,>r for a Gcccu c<
legal natu;of cn=aploycr under tl:o wozkc'.l o xr alien�.ct
I uadc-'ziaad thL a copy of tlu ctatcis_'r-:.y fof—,v Sod to tl»IY_Sxi LZ cr of lr.d s!riJ Accj&�•a'o iao of for U}
ooverAF�c vcriBCrAioa and that failure to:ratr. 25A of MOL-152 rin Icad to the i• r-sition a.cr ir_l pr sll:ca
outing of a fin,ofup to.S 1.500.00 mn:�Inr i^:tr: .� , of::p to cr..)-t ..:.I civil-,KmItia in d�fcnn cf a Sir ti'c i.<h ar l a
Lrtc oC:,100.00 1 day
- - - )
� ._ to[-cSq=utnYStaJ u.c oily
nature cif..ic nr cJI'°rnli;tc!' °`r
f 1
SECT ONB CONSTRUCTION IS'ERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Re a Fe WM-Rz.rn vem°en on#rac or. Not Applicable ❑
,t` v tv
Company Name + Registra ion Number
Z'Z,!Z L 11 HV7L11
Addr � 1 E xpira ion Date
< <-° Telephone 1
SECTION 10 WORKERS' COMPENSATION 1NSURANGE,AFFIDAVIT(MG,:L-.c. Y52, § 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)famiies
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 far 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
I .
i
I
SECT�10: y ES x AIONFP,ROPOSED VI/ORK checkal a I�cable 's
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: en f " t
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
5a. -tIe+vt�ose
to Ma tli#rontoezistinhous=ing;c"omplee' Nefol=lowin :
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
SEC IOT+t WNER�L)��IORIzA ON 'TO'BE COMPLETED WHEN
OW'NftSS1ENiDCONTRACTOR`APPLIES FOR BUILDING PERMIT
i, 46 i V //Q as Owner of the subject property
hereby authorize 41 to ac;. or
my behalf, in afters relative to wo5jk authorized y 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 Name
Signature of Owner/Agent Date
w
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:
R
-�` Jail* bf;Northampton
Bui�ding Department
21_ Main Street
Room 100
.Nprt�amp�on, MA 01060
p `bt1�'aY , �587_J2+40 Fax 413-587-1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION'1 - SITE INFO'RINIATI`ON
1.1 Property Address: This spec#ionQtob ompltelbyoffices
.3 Lro. I
1 <_'�✓(F/1(( /Z/�/� , :Zoned Overtly Des#r c#
Elm StDistrict CB District .4
SECTION:2 - PROPERTY OWNERS HIP./AUTHORIZED AGENT
2.1 Owner of Record:
Name(Printl Current Mailing Address:
Telephone
Signat re �
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION'S ESTIMATED CONSTRUCTfON
Item Estimated Cost (Dollars)to be Off icial Use Only
completed by ermit applicant
1. Building (a) Building Permit Fee
2. Electrical (b) :-::stimated Total Cost of
Construction.frorr 6'
3. Plumbing Building Permit Foe
4. Mechanical (HVAC)
15. Fire Protection
6. Total =(1 + 2 + 3 + 4 + 5) Check Number
.This Section For Official Use Only
Building Permit Numbe..r: Date:l"ssued:
Signature:
Building Commissioner%inspector of''Buildings Date
4 �
". BP-2004-0462
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0462
Project# JS-2004-0664
Est.Cost: $6000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Edward T Corbett 119488
Lot Size(sq.ft.): 14461.92 Owner: SHAW HARRIET E
Zoning:URA Applicant: Edward T Corbett
AT. 310 BRIDGE RD
Applicant Address: Phone: Insurance:
1 TERRACE VIEW (413) 584-2546
EASTHAMPTON MAO 1027 ISSUED ON.10121103 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 10/21/03 0:00:00 Mo $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo