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DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR 212 Main Street ® Municipal Building
s
Northampton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as !Js/her construction sul; : . sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on wh h he/she resides or intends to be, a one or two family
dwelling, attached or detac ed structures accessory to such use and/or farm structures. A
person who constructs more an one home in a two-year period shall not be considered a
home owner."
The building department for the bi'ty of Northampton wants any person(s) who seek to
use the home owner exemption, to"4ct 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 pros ss requires that the building department be called
to inspect work at various stages, which incjdde foundationfoundation/footings (before backfill)(before backfill),
sonotube holes before your),_a rou l� ildin inspection before work is
concealed insulation inspection if ' ired and a final building inspection. The
building department requires these i spect ns before the work is concealed, failure to
secure these inspections can res tin fail re to obtain a certificate of occu van c
until the work can be ins ecte .
If the homeowner hires other ades to perform work (electrical, plumbing& gas) the
homeowner will be respon'i le to make sure tha the trades hired secure their proper
permits in conjunction to e building permit issu , and that they get their required
inspections. Failure of t e individual trades to secu e the permits and inspections as
required can DELAY e project until such time as th proper permits and inspections are
made
I, understand the above.
(Home own /resident's signature requesting exemption)
I will call to s edule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
locatio '
B=o � � 16IflJ of artlialliploll
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UEPAARTMENr OF 13UII-DI?,,YC INSPECTIONS
212 Main Street Municipal Building
Northampton, MCLES. 01060
NVORKER'S COMPENSATION INSURANCE AFFFDAVIT
ct
I
(l i cans;dI c:m!tt cc) i
with a principal place of businesslresidence at.
I�
`J (�lholw
CIO hereby cC:l1I}+, 11Il;�CC tll(' l'i;'.Ir1S atic pCimitICS of pef-illry I,Ilit'.
12II1 an CI11ployel prOVldln� the I011Owlns; '.vofkcrs c.0111I c:ls:il!0I1 COVC:f:'�C 'Of In}'
employees working on Enl,s job.
(Insuiana Company) (Polio:Number) (Llpi ion Datc)
O I ani a sole proprietor, ,,encFal contractor or homeowner (circle otie) anti lured
the contractors listed belov-A ,who 111-17e the f011o•,v:nQ workers c-ompensation �olic:es:
-� (Name of Contactor) (Insu.nc: Comoany/Polic}+Nucnt�:l I=xr.r�I_en Date)
(Name of Cclntac;or) (InsuFanc:, Company/Poticy Nulnt-�r, Date)
(Name of Contractor) (Insurance Com-pany/Policy N111ntxr) ( s;::r,:doa Date)
---------------- ----------------
(Name of Contactor) (II1sZ1ance: C01111-'any/11ol-icy (I-1-i:i:.1[1o:;Date)
(attadr�dai�msl z'xct 1!::oc<s ir:cn io-_iw`c ru,cKruti
or
i
,I Iull a sole proptictof tt:lti have no 011e -,vofkino for ate.
a1I1 11 hOn?t OAv?1C: peflo-1111118, all the v"Ofi; iiiYSClt.
NOTE:plc sc tx awi-:c tl:a''.� i1c k rro�ti�ria���c npl ry;x zos w c:�c_su cync a.:. n d r<a tcpair �«tl!i^;c�
¢ol tixre t1Ln(lace utri+�in tc{;:cai•,lx hr,ivuixr rr_:.'�or oa L'w:�:u:>,'s zpfurtcc•-•nt L>CC.o r:2 tn<eclrrallV c<,::::::::�:�h
calploycs tl)e world's cc :- n Ar (GI.15oYs1(S)),r.ppI ccatic=by n home*%(-ci!cr c I: c ct
legal etatus of an o�ployor under tL•e W«lei a Coen;mn�iion Ace.
I un&-:It d fh.t a copy of tfii ct.t--t mwy 1 o fcK---ded to tbM I?ctrertn--A of Ind u i l AtxiLatif Offi—of!: u.•r_a for tf»
eovaase verificatioa And t11-t f-ilurc to r%. uc C01,-C t•EZa ur.6,-r cctiea 2 5 A of MOi.152 can lc--A to the imposifiort of
coaitsting of a fux of up to S1.500.00 an"Cx imprisnamcril of up to on year AM civil perultics in de ftxin Of ft Step VVc l Onic-:d-
fine of 5100.N i dsy I-pintt ar_-
rFor d4,,anntal u.o ally
Pcimit�Itullbcrr �
�'1-
I F
S i gnature of
SECThON N18 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address < Expiration Date
L
it
S � 7 �
Signa re Telephone
Reis eredome movem'ent¢Con"t actors ;, n .G ,e Not Applicable ❑
b f 7 0'7
Company Name Registration Number
Address C Expiration Date
Telephone 5"/y SLI
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...... ❑
in
I
>oam ® gne
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 j
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 buildinil permit.
As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon i
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
i
SECTtONyS= r ES R PTONOF�PROPOSED WORK ka
checll a licable
s � Ucw�nn,aza sa<mira - ux d as-..�a nnr _ „r i v vc�
: ""�'lX`°nw'�ca�'*�sr''"�.: '.ka�`iY�'Jk� 1 rt.�h-t •Ax"��nd'
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Sidi] Other [ ]
Brief Description of Proposed Work: �`� L° qty f cC tt .c V i ,►
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
saIfNew�house a"n"do c�dition5to�existing�hou"s`ins,�a.cortp'lefthefol°lo�v'in�:
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? S
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 .
1. Septic Tank City Sewer Private well City water Supply
SECTION 7aaOWN'ERAUTtfORIZATION TO BE COMPLETED WHEN
OWNERS'AGENT,OR,CONTRACTOR'APPLIES FOR BUILDING PERMIT
J,
et 4 .1 as Owner of the subject property
hereby authorize !c,'-A �vC� �(�"� to act on
my behalf, in all matters relative to work aut ized by this building permit application.
Signature of Owner Date
1,4 (CZ 1 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.
fG °7
Print Name
Signature o Owner/Agent 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:
it of Northampton Satus�of
VB Idt epartment C 'G' U
7= a
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s in Street Se er/Se lc al a I '
100 Wat�erJWe
�' AUG ' � ��th n, MA 01060 Two wN,-,- 413-587.1272 ,
phone 413 58 12 0 Fax Plo#/SlteP a s ��
DEFT OF BUILDING INSPECTIO Other Specify _' lvi
AP D LTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING —
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This section-to be completed by office
f
IG IV - ��� Map Lot Unit -
0 ro—'l Zone Overlay District"
Elm St. District CB District---
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
pp
---RC�to D ra
Name(Print) (,.rrent Ma tr Address,
2.2 Authorized Agent: / f
Name(Print) — „went PJai!Ing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit a plicant
1. Building (a) Building Permit Fee
2 -ie--rical (h) : ..timated Total Cost of
Construction from 6 _
3. Plumbing i '--- - I Building Permit Fee
4- Mechanical (HVAC) l
5. Fire Protection
6. Total = 0 -+ 2 + 3 + 4 + 5) f, �j' Check Number This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
. 3
w� 1 BP-2004-0109
mpti
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:vinyl siding BUILDING PERMIT
Permit# BP-2004-0109
Project# JS-2004-0175
Est. Cost: $5593.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Quinlan Builders 101707
Lot Size(sq.ft.): 17641.80 Owner: BRAMAN HELEN F
Zoning.URB Applicant: Quinlan Builders
AT: 188 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
5 Hillside Dr (413) 585-0949
HADLEYMA01035 ISSUED ON:814103 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE FAULTY VINYL SIDING
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 8/4/03 0:00:00 3623 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo