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"s" DEPARTMENT OF BUILDihG 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 has/her construction sups:-, 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 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
Afio �o�`ti (rTff I7f �.�QL"f I,<i111�IfD11
B E ��asaArllnccl(a'
Q DEPARTMENT OF BUILDD,\G INSPPCr10t.'S - —
212 Main Street Municipal Building
Northampton, Hass. 01060
«VOIUCCR'S ON'PENSA7110N MSUFtA1�'CE AI�ItTI)AVIT
_— (li ccvscxJ(x-rmi tfcc)
v"ILh a princip place of business/resideoce at:
(phone:')
(sti-�t/c�ty/stalcla p)
do hereby terrify, under the pa-ins and penalties of peflury:; hat
( ) I am an employer providing die following xvorkcr's comocnSSdo, cove ale for Illy
troplovecs woriong on this job.
�c Conn:m) lPolic; No r) (.=:-pirtSor,D2j—^)
I am a sole proprietor, general coorraaor or homeowner (ciucie one) and have hired
e conuactors listed below wbo love the follo%viog worker's co ptp—sa ion policies:
-
(t+IIIIIe Of Co =cio-) (IIlwranc: Coinpan)-/PGUCi 1111c)
(Name of Cooncior) (Insur-anc: Comoan)vPo6m, NILLm cr) (E.,DT.:tion Date)
(Name of Coacaclo,-) (Insurance Compan)-/Polic)- Number) (E%pLrz6o3 Datc)
(Name of Contractor) (Insuraa= Compzzy/Pot cy Numb-`r) (Evpirtian Date) .
(aIIacb '�..peat tSc�,ifnc --v w¢tcuc�inforaa.��oc pc:Za.iaia.s to..0 ooa�-to:�)
( I am a sole proprietor and bave no one woridng for me.
( ) I am,a home owDer perfot-rn' c, all the work myself.
NOT E:plesc be cMrt o".wi 1e bca4c k en�to carp lay Pcwm w do � -e,00 r rcRV-Dr-X CIZ. of
aot taocs t�.n L' -tars is-Escb the bot -o
noo m-=reaido or oa the pu�zFpu Lc tbee a. a_-.12
n pot� y 0--=.d-vd w be
c mploy=uce--the 0==P -..,'co Aa(G Lt SJ_s 1(5)},:pptint oc by.bommmva fcr c lip-.or pcsma riy cl-idcooc the
legal wu of a.a e:ployec aador dap work e,Compoasalioa AeL
I u-6--.ad tba a ropy of thia=LL—.=m.y be for-xurded Lo tba Dopartmm¢of I-A—,;j ,-d-tY Offi-or lx-u�[of tb,
coveaEzc "=iGalioc And Uu L•LM to saaarc'coveryse toad=soctioa 25A of),((DL 152 cna led to the i=Posi6oa of cimiasl pc`W(=
000aissxg of a fiat of up to s 1 Soo.00.rzfc>r is rizocz»r or up to oa yt=e.od ci vij pcaitia in the form or.Stop Wort Orti=end a
rtm of S 1 00.00 r d_y LPjc a me
_ For dc9.rca'=�ux Doty
' �... Pcrm�[ rlllIniK:S
Lot ^ s.
Si tun; f Li Jpermiuc,—
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9_Registe�ei';1 Fo '�.m� �errtoiifractor `t Not Applicable _❑
Pp
COMDany Name Registration Number
7�s
Ad ress Expiration Date
?-407c5
Telephone
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...... ❑
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 buildine 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable
New House Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [a Siding [O] Other[C7]
Brief Description of Proposed
A
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa:It I�erNioase arrl= addtl® to exi`s#nca pious riurcim olulnc:
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
L 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 F,OR"<BUILDING;PERMIT'
as Owner of the subject
property
hereby authorize
to act on my behalf, in all nioers relative to work authorized by this building permit application.
Si nature of Owner Date
I, as Owner/Authorized
Agent hereby d c re that the statements an84nformation on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of per'u
Print Name
Sig a of wner/Agenf 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 7— % 7-7
(Lot area minus bldg&paved i
#of Parking Spaces
(volume&Location)
A. Has a Special Permit/Vorunce/Fnd ever been issued for/on the site?
NO K J DUN7KNOW 0 YES K X
IF YES, data issued:
IF YES: Was the permit recorded at the.Registry uf Deeds?
'
NO 0
IF YES: enter Book Page,'
aU and/or Document#| |
B. Does the site contain a brook, body of water orwetlands? NO 0 DONTKNOV 0 YES v~�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tnbeobtained v~��~� Obtained v~\��� �otm |usuad'
' . '
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: /
/
�
D. Are there any proposed changes tomadditions of signs intended for the property? YES � NO �
r--
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre n,isitpart oia common plan
that will disturb over 1acre? YES ���l NO �l��
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northamptontauso€ eta
Building Department , a �ea �� � � _
.212 Main Street ew ter 4
' Room 100
Northampton, MA 01060
php,"413=587-1240 Fax 413-587-1272
Nil
APPLICATION TO"C-OrRUC ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
I•. q,.)
SI CTION`1 SITE INFORMATION
1.1 Property Address: _ T�fiissectwn to tie competed--,b"office
G���i,�2✓U°�` Map . dot Uru#
Zone Overlay 33istcict
Elm t'Distnct��r CB,D�sfi�ct "
SECTION'2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Reco d:
Name(Print) Current Mailing Address:
�
Telephone
Signature
2.2 Authorized Agent:
Name rint) Current Mailing Address:
5
Sign re Telephone
SECTION-3 ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
complolyd by ermit applicant
1. Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing 113tililding Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
i
6. Total=(1 +2+3+4+5) Check Number
This.Section For Official Use Onl
Building Permit'Numbe Date
r.
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2008-0473
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Catep-or : BUILDING PERMIT
Permit# BP-2008-0473
Project# JS-2008-000704
Est. Cost: $7000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: James Roberts 117154
Lot Size(sq. ft.): 22389.84 Owner: WARGA SUSAN A
zoning: RR Applicant: James Roberts
AT. 228 AUDUBON RD
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON.111212007 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
tJnderground: 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 11/2/2007 0:00:00 $25.003366
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo