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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 108.3.4 to
act as his/her construction sups:,,isor. 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
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C�lzitl Of � �J17H)Ulllpfn>>
6 �3}[aSftr}1116C1I7 � -
^� DEP/u-tT'MEPN71 OF £UILDf)�G INSPECT'ioNs
212 Train Street ' Municipal Building
Northampton, Afriss. 01060
WORKER'S COMI TE•NSA`I`ION MURANCI: A FF-DAVi.'T
�:ith a princip El place of btlslnesslr, :sidcne
do hereby cer-dif), l!IlaCl the 11%!75 i'.nj pCil lt] S of per�Ell illat -
l am an crlapioyu pmviding the iolloP:irl :<)i''r;CrS cotIl)=S?L10i] fo, Iny
employces working on this job_
(Inslranr' Corsram') c c;NuzibCT) ---- (Fxpir2tion Dan)
I ac] a sole proprietor, geaerLi cow,='cr yr homeowner (C cle one) and gave hired
01-1 con-mactors fisted below "-ho ; the ollC ' � er 1 e �'
:pry � orri s c.o,:.p n . on
(' amc of Contmcto n�u rice rn T ) r> :+•._cc Datc)
.) Ci Cor ...�;. o1ic� 1�n�r ,
(Name of Contnctor) (7]sJr,rcc COu�c:i`'IPG!]ct` NE rltr r) (1-`D 'atio:l Date)
(Name of Contractor) (in;•�r nee ComESr;iYoGc, Numr��r) z;.:r�:,io_ irate)
- -Name.of Contractor) —- (Iiisl railc Ceinr Y i olic Numb-z-r)
^tUdl add+�n:zl rt:xt:`.• ::�: ._.... _...•)
C 1 ?ull SOIC prol)I'1LtJi 2;1 1 haV, ilo OIl'v '•',' ':; fOr iI1C.
home 0]T,'I1C D i?C"I:I III^ a[
*iO IT;;plcusc Er n:vy c t+:�::i:a)c lxcnco lr a.:ro -,p
not Stcec ih n[)>rroo uniu in tti `t uhe l:rz :t r r=: s
o<o --:-t n_t Scrr�lly
cz.,ployc3 u_n.�4r_tvori'. a :_.icn %C7"(GL`.52-31(5)',a,:,•lin:io;by hotncou rr`cr c Lcc c c�p:�s:i::. :-rx
1�911 ctatua of an o1o}•er un or tLo UJcv�crt oi;ar Ilion .cL
I ur�de-:taad tht x copy of(iu ctatc:a'may bo fotu.uei�S to ti»IYtxi u: ra of leis riel AC66�&(Dffl v of i::::—for tim
coverage vcrificii0o&nd that L•ltuc to _a rc co'--T i7„ur,kN-r4C*iM 25A of MGI,152 tntn lr�.d to tl)c i,,nr M-:1 pain:s
ooaiuting of a fur_of up to S I-SOU.00 n:t"' r i^^I:rivr.^ti:1 of::,to cr:y-s.:,j civil rnztlin in ut tc to cf n Str,,`.Jni:C}C�3rd
f m of sloo.DO a dsy againa m:.
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- for dq:uutrstsl u.o qtly.
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S�CT�ON 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : C? (96"0 — 3C.d
License Number
6A tc- r-141 l C Olt 02(.1 _4 Lli I o
Addr Expiration DA 2- u( ' 413 & 3
Signature Telephone
Reg s ere ' na mp ore ent� ontracto _ Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 3a "WORKE3RS' COMPENSATION INSURANCE-AFFIDAVIT(M.Ga_:.c. 152, § 25G(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....... i eo 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-vear 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
SEC�T�O� q. �.� ON{t4°F�°ROPOSED�INORK checkll� lacable <,� �,����;
gym, .... PN! IM
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Itl-
Or Doors O
Accessory Bldg. ❑ Demolition❑ New Signs [ ) Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: � . : ��
sh h/ roo-7'(-,n y f ,ui 0 c.S
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll❑ - Sheet❑
a�
d o1 ME VOnAo exM1 - uo sing o e, a tie llow�-g:
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. bimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masc:heck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 fit. 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
* ECT1�1J NFAUeOR(ZATION TO BE COMPLETED WHEN
NE S [ TAR CONTRACTOR APPLIES FOR'BUtt D11VG PER,
as Owner of the subject property
hereb orize "�� G -lifi to ac; on
my behalf, in tter elative �fwork authorizAd by this building permit application.
Signature of wne Date
as Owner/.Authorized Agent
hereby declare that the statements d infor atjon 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 Namg_
CQ
Signature of 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 l �irj 1
Frontage
Setbacks Front
Side L:Ayo!R: 3 C L: R:
Rear gp
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, desbribe size, type and location:
........ .........._.
City of Northampton
Q (� ing Department
l� 2 Main Street
j Room 100
1 AUG 2 8 ��03 No� pton, MA 01060
phone 413-587-1240 Fax 413-587-1272
F nFR1J11D1Nrj1NSPFrTf0NS
M 011
T, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This sec�to ,, o`be corntEdFbyoff�c
M5 _/".1 F�C.�I���C1Y� �ac. - >Map
J nZone � v r D�str'
.>
ElrnSt District` .- � CBistrict_
SECTION:2 - PRO:PERT>Y.OWNERSHIP✓AUTNORIZED AGENT
2.1 Owner of Record:
Na e(PrjA ) Current ailing Add ess:
Telephone
Signatu e
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
/
Signatur Telephone
SECTfON;3 - ESTIMATErD 66' TRUCTION`COSTS
Item Estimated Cost (Dollars) to be Official Use°Only
completed by ermit applicant
1. Building �/ ' (a) Building Permit Fee
J
2. Elec`.rical (b) 'E timated Total Cost of
Construction ifrom 6).
3. Plumbing Building Permit Fee
i 4. Mechanical (HVAC)
15. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check number
This Section For Official Use,Only
Bui{dipg Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
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395 AtJ ! ±T 1 BP-2004-0232
GIs#: COMMONWEALTH OF MASSACHUSETTS
. '! CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0232
Project# IS-2004-0336
Est. Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: ROBERT QUIGLEY 053436
Lot Size(sa.ft.): 386377.20 Owner: BASKIN LEONARI>&LISA
Zoning:RR Applicant: ROBERT QUIGLEY
AT. 395 AUDUBON RD
Applicant Address: Phone: Insurance:
95 BERKSHIRE TRAIL (413) 634-2123
CUMMINGTONMA01026 ISSUED ON:8128103 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 8/28/03 0:00:00 9710 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo