17A-210 (2) O�TI AMATO
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DEPARTMENT OF BUILDIJ\IG 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 his/her construction supe:-:il 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 rouzh 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
i -
,•� -E U�I�� IIf ��LILfl�i�lll�Jf011 — _
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W DEPARTMEI-T OP DUILDf\1G INSPECT101JS -
212 ]\lain Strcet ' Municipal Building
j Northampton, Mass. 01060
WORIQ R'S CONAPENSATION LNSURACE AI'I MAVIT,
1
(li c�nscxlpermi t'cc)
%Vich a principal placc of businessfresidence at.
!i 1ZL. AA L2�- �� � !�'�t' C��C j�j(1 hones') ��
(sa�.t/ci ty/sYaicfn p)
do hereby cerdi ,-, under Llic.pPins and penalties of perJury, -.hat
( ) I am an employer providing the followinL iworl:cr's comocnsado, cove mge for Inv
i
emplovees worUng on this job:
I
(Imnu-n Conn m,) (Polic:Nub-cr) (r:-pir`tion Dam)
I
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( ) I am a sole proprietor, general conu-acror or homeowcer (ci c:e one) and have hired
the consactors Listed below wbo hive the following worker's comoep_saaon pakles:
(i`+amc of Cont ctorl (InR rant CGt1701r1)'/PGUCi
I
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(Namc of ConmeZor) (lns-d=Cc Comoanti•/Po!ic}• Numcrr) (-L:x#.:tion Date)
(Name of Cottrraaor) (biTw-aaca Comp.an)•/PoU-q- Number) (Expiradoo Datc)
I
(Name of Coaimcior) aosuraac-- Comrzuy/Poticy Numb,:--r) (Expiration Datc).
(aaac3:.ddi� c5c-,ifncC---v to ctchscc inrormx.joa P=AA aiag to alt oo=--co:�)
i
( I am a sole proprietor and have no one work-ing for me.
( } I am.-a home owner petfotTning all the work myself.
NOTE:pl=-,x be eerarc ti- +--.Ic bc,,,=O, . ta-bo caaptay p�-%A=to di m= c==-•r..jao a tczzu-ork oa. of
GO(mat than t. 'Oc tmfL,is winch tux bamoawocr roach tx oa the tbe-eo z- out ccne--ty eccridertai to be
-vloyea tanc a the--S u^s cam---..:oa Aa(GLI152-=1(5)�=,-gU=,6oa by a bom.Qaa fcr a 6c=----a pczait n_y c%id—thC
IcS21 Hive of ea-Moyer uadar turn Wortr -C c*om..tiaa Act_
I
I-d--ad that a°Dpy of thia mteme=ov.y bo fac-rd-d to tho op—t__¢of Ac &=Y OT-of t—for th.
covc` vciLmina And nu L-i)tac to A—)—craw under seetioa 23A of h(GL 131 can ta.d to the is po OQ of aimiast Pea-16"
ooavSmg of a fiat orup to s i}oo.00 nd/c r im{auooa t,=orup to-cc y=end avit Paoatiia io be roan of a Stop Work Ordcr and.
file of S 104.00 t dsy Lpiaa me
,. For dye-^ -'•t uae only -
J � Pcrmil Numixr
1.(np°—_ Lot n
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SECTION 8-CONSTRUCTION"SERVICES ",:.
8.1 Licensed Construction Supervisor: Not Applicable
Name of License Holder
. License Number
Address Expiration Date
Signature Telephone
pplic
Not A licable ❑
9`tTerii�istere Eonrefimpi<c7v/emee CanfEacta
CorinvainV110me „ RdIfftfation um er
Address Expiration Date
Telephone L//,5
SECTION 10-WORKERS"COMPENSATION INSURANCE AFEIDAVLT(MG L,e. 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 ilding permit.
Signed Affidavit Attached Yes....... No...... ❑
M Mme- -
MOO">
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
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check'aff ayOicable)
New House [] Addition Q:. Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[0] Other[cl]
Brief Description of Proposed
Work: �J 2 I✓l CL✓ 6,(A
Alteration of existing bedroom Yes '" No dding new bedroom Yes "'No
Attached Narrative Renovating unfinished basement Yes ----No
Plans Attached Roll -Sheet
x.,.�4.- �_r- +,rte. ,.`•';;�SY"x �eY fw"a-r..S.+�"� +.,',�'`°.a� Y..:��. ..r:'- .�--..'�.^:'rt,�%��.,m+3 tea-_' :. 'q�""�'�,5��
sa..l �le���oas�and �addt<i<ra�o�e >stin or:�s[fr :Cary �ete��Eh [tQ�f>
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 Tank City Sewer Private well City water Supply
SECTION Ta-OWNER AUTHORmATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES.FOR BUILDING.PERMIT
I Of c7� Lt fL as Owner of the subject
property
hereby authorize x �—<-
to act on my behalf,i all rhatre relative to work authorized by this building permit ap 'cation
f
4112- U _l 5
gnature of n Date
as Owner/Authorized
Agent hereby tare 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 UU34 � -
`
Signature c caner/Agent Date
_
Section 4. ZONING Al I Informati6h Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
T'his column to be filled in by
Building Department
Frontage
Setbacks Front
Rear
Building Height
Open Space Footage %
(Lot area ininus bldg&paved
#of Parking Spaces
A. Hasa Special Perm been issued for/on the site?
NO 0 DON'T KNOW YES 0
�
IF YES, date issued:!
IF YES: Was the permit recorded otthe Registry of Deeds?
NO 0 DON7KNOW 0 YES
IF YES: enter Book Page, and/or Document# |
�� ��
B. Does the site contain o brook, body uf water orwetlands? NO �—J DON'T KNOW «_� YES �~�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
-
Needs tobeobtaioed v~~� Obtoiomd �~\ Oa�m �ssom�'
«�� «�� ' .
C. Do any signs exist un the property? YES K ] NO K ^�-
IF YES, describe size, type and location:
O. Are there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location:
E. Will the construction activity disturb grading
i ~
filling)over 1 acre o«isb part ofa common plan
that will disturb over 1acre? YES NO ~^ ~'
|F YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton ` '
1.
Building Department .
a
212 Main Street
Room 100
Northampton; MA 01060
phone 413-587-1240 Fax 413-587-1272 ' n
_-
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APPLICATION TO CONSTRUCT,ALTER,REPAI k-R OVATE OR-DEMO-LISH A ONE OR TWO FAMILY DWELLING
SECTION 1.-'.SITE.INFORMATION A�' LOGJ
1.1 Property Address: ` k This sec on to be corsipfetedbyoff[ce
` Cap�.,�
",
ToneOuerfaY Disfnct
w
ElmStr District '�.: =
SECTION 2-,PROPERTY OWNERSHIP/AUTHORIZED AGENT"-
2.1 Owner of Record:
\ vc, 1 r ,P Il(0—
Name(Pri t) Current Maili.A dre s:
Telep-
Signature
2.2 Auth zed Agent:
7)( lo-il B I-u C-X. Pf Sec k vl��
Name(P it
Current Mailing Address: p /
ignat- J y/3 �� 7 b Z—E6,
Telephone
SECTION 3-ESTIMATED CONSTRUCTION'COSTS,
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 3 (a)Building Permit Fee
2. Electrical 1 (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) Check Number /
This Section F&Official Use Only
Building Permit Number. "D a t e
Issued:
Signature: r
Building Comm issionedlnspector of Buildings Date
BP-2005-1028
COMMONWEALTH OF MASSACHUSETTS
°O CITY OF NORTHAMPTON
Building
BUILDING PERMIT
# BP-2005-1028
# JS-2005-1405
Ist: $3400.00
X5.00 PERMISSION IS HEREBY GRANTED TO:
Class: Contractor: License:
trop : DOUGLAS B LUCE 136057
ize(sq.ft.): 24916.32 Owner: HURLEY DOROTHY B,D MOMSON,
, :URB Applicant: DOUGLAS LUCE
AT. 116 NORTH MAPLE ST
rlicant Address: Phone: Insurance:
' AUDUBON RD (413) 584-8786
:DSMA01053 ISSUED ON:4122105 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE MANSARD PORTION OF ROOF
JST THIS CARD SO IT IS VISIBLE FROM THE STREET
spector of Plumbing Inspector of Wiring D.P.W. Building Inspector
nderground: Service: Meter:
Footings:
tough: 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 4/22/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo