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,.Sn DEPARTMENT OF BUILDING INSPECTIONS /-
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as i:is/her construction sup,-,: •.•i:or. 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
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
f
O�-(ll/Jf
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A E 31=�anchrtsc 11 a'
d DEPARTMEtrr OP BUtLC)r.\'C INSPPCr)o1.rS -
212 Main Strcet Municipal Building
?Northampton, Mass. 010G0
WOMCER'S COQ PENSWIZON MSURA CE Al=, Atiri-j'
(li ^rJpcmli ttcc)
a pt-,-tcipal place of business residence at.
i (phone')
(snr-c/city/st uc/rip)
do hereby certify, under thc.ppinS and penalties of perJury; :hat
( ) I an an employer providing die following tvork&s comocnsado;: coverag e for m}
emplovccs worlorig on dais job:
(Losur� Corer ) (Polio: Nu-mbccr) -- (' xpimtior, Dam)
O I am a sole proprietor, general contractor or homeowner (ccie one) and have hired
the contractors listed below wbo have the `oUo%v>.0g worker's r01- oenszaon policies:
(I+3IDe Oi C0 '_^Ci0') (InSVran COtnoan}fPouc; ?�rlLQl.G') (1-`;Jmwuon Datc)
(Name of Cootraor) (Lnsilraocr- Comoia.a}vPoUcr Nut -zr) (`E-%DU7Z-.6on Date)
(Name o(Connaaor) Clmsuraaec Compare)-/Pouq- Number) (Expo'z600 Date)
(Name of Coacmcior) gmsuiaacc Comczuy/Pobcy Nu.mly`r) CExpirdtion Dau).
(an, addi;:ocal 6ca,ifncca -v W mein iarortaa ioo pertasaias to.11
am a sole proprietor and have no Oct world.ng for me.
( ) I am..a home owner performing all the work myself.
NOTE:ply cc be eoArc Lei k{i)e bcmeoµvcra-bo cmptey pa-1-ow w L,3 r. c=r.r oo c mau warX on c d..c11_�of
ant moot tbxa L eta to u3ich the boa=-^ r raid=oc oa the grow ndi z7purieo.:r1 tbeu t,roe Carlly o,=-d=-cd to be
c=Vlcycs unGc the`vim's O=P—==oa Act(GL152sa 1(5)�_ppliaAoo by a bomcoavc fc:r c liazw.a permit rr y crrdmoc LL,
I,-pI naau of en-=ploys under dro Work. '.Comp.em,.t AaL
I r+adcrund tha a Dopy of thi.-M cL m may be rocs ordeal to Lb-Dcp.rtmryr or Iodutricl A• d—om-of I,-+r+oc•for Lb.
covcstSc waif eaioo and tltu L-i L-m to socu,t co%-crr- tsd,=sp=oon 2 5 A of hMOL 152 can Iecd to the impolIIioa of airmail pcnzlri=
eomisiz or fiat or up to slSoo.00 and/or o(up to ooc year e.od avi)pcm�ltie in tSc form or.Stop Work Order read a
rim of S too-00.day can cy-
For only
( Pcrmjt NUmt-Cr
C) Lot
SignaLutr of LicaLscz- permiucc 113LC J F
1
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: (� Not Applicable ❑
Name of License Holder: G) \> I� ,i V O O `+�l b S 6 9 C
License Number
`k f Ck 1 S4- a C, 4,3- o--�
Address Expiration Date
4 � .:�,-Q-o1�► �-i 3 Ste' '7� 7
Signature Telephone
AdeyftePeLl'I omG tTlfQ oY @Tlle1TG�'O ltfa Ofw s � ,a���':�,.n�a�t S- �w.»awa r�...�..,:
"3 Not Applicable .❑
� � o C� to �. -�. ► �in�
Com6a-nv Name J1 Registration Number
vy" o
Address r Expiration Date
Telephone �� (r,3
SECTION 10-1 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 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
r f '
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors C7
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding [O] Other[0]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No �� O
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
elrl w�.
Ba If�Iew haDSe'and or addrt>Iar toe is incr.haiasmg cnmplet nag:
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. Masscheck 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 Tarik City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION--:TO BE:'COMP.LETED WHEN
OWNERS AGENT OR CONTRACTOR•APP.LIES,FOR;BUILDING PERMIT
C_`(- f S as Owner of the subject
property
hereby authorize ��C7 \ t1 v;��V�- y
to act on mr behalf, in all matters relative to work authorized by this building permit application.
_ `6
Signature of Owner Date
I, a �j �,2j(O'�) K) 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 Nam
?�'� a
Signature of Owner/Agent Date
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
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
Open Space Footage %
(Lot area minus bIdg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Variance/Fi nding ever been issued for/on the site?
NO 0 DONTKNOVV YES 0
IF YES, date issuod:
IF YES: Was the permit recorded at the Registry nf Deeds?
'
NO K ) DON'T KNOW 0 YES
IF YES: enter Book
Page and/or Document#| /
'
�`� x�� x~�
B. Dues the site contain a bruuk, body of water or wetlands? NO �~� DON-17 0VOVV �~� YES �_�
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained x�� Obi «�� Date
«~~� �~� ' �
C. Do any signs exist on the propert �� ��y? 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 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre orinitpart ofo common plan
that will disturb over 1 acre? YES ��[ 3 NO [D
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
� x
City of Northampton.
Building Department'
fit'�c1.a`'
212 Main Street � �W �
Room 100 �o 6 G 2 � a� � � � ��� x.
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION'
e"ciyafce This secwn to bm
1.1 Property Address:
�INap �'ot 'lJnit
S Z Overlay l<3istncf
�GI L� 6�� �1�P l � one
p `C"e V"\C C �.EIrn St Qistrrct GCB IIisirrct
SECTION'2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
?j--m \�a, Y G Y-C-,v t s
Name(Pri11� Curr nt Mailing Address:
\ A-cam Tel ( o Gf 7
� O
Signature
2.2 Authorized Agent:
9N n \-� -- ::VA �2) Q)� b Q o b o U CA
Name(Plnnt) C rru ent Mailing Address:
Signature Telephone-T SECTIOW3-'ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
-
completed by ermit applicant
1. Building (a)13uilding Permit Fee
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) c) O Check Number
This Section For:Official Use Onl
Date ._
Building PermitNumber. Issued:
Signature:
Building Commissioner/inspectorof Buildings Date
r �
194 NORTH MAPLE ST BP-2007-0340
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-223 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2007-0340
Project# JS-2007-000504
Est. Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: BOB THIBODO ROOFING & SIDING 152172
Lot Size(sq. ft.): 12806.64 Owner: HARGRAVES WILLIAM J&HOLLY R
Zoning.URB Applicant: BOB THIBODO ROOFING & SIDING
AT: 194 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
P O BOX 201 (413) 527-7663 ()
NORTHAMPTONMA ISSUED ON:912612006 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE FRONT ROOF ONLY
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 9/26/2006 0:00:00 $25.003174
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo