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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR
212 Main Street • Municipal Building
Nordi,-unpam, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCNM 108.3.4 to
act as iris/her construction sups;:-.`:_-or. The stare 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 occupancv
until the work can be inspected.
If the homeowner hires other trades to perform work (electrical, plumbing 8, 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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L_IX
a I I ip [I I I
R!l77 r
n s c t I
DEP/JRTMEWT 01; BUILI)MG INSPECTIONS
212 Main Street ' hfunicipal BulUng j.
Northampton, Mass. 01060
W 0 RICE,R'S C 0 MT EIN S A TI 0 N INSUIZANCE AYFIDAVIT
V.,!d) PrL,jlCIp4-d Place Of buaincsshnidc!ICc �.r.
,.;"(j. 0; 0,;Z 7 /_3 56r7
; -0
f an employer provldlmg Collinnsn011 for my
wor�drig on t1m Job-
CJ C a7 ACI I 45R
(Ir-s-ar
a Cf Comp2my) Nivai•er)• (Ex r,i rn 0:,n Da i c)
1 am a sole prop'lCt0r, QUIPFai C.:)LIJi:C-CF `,om
c-o%vDe7 U
(c*r de oriel ant' tldfed
Cont-'actors listed beliow v)-ho
S
of
(Name of CoutT?.clor)
Da:e)
of coaL pct o,)
(dame of Contractor) Jasuranc� Dite)
110me ov.
M 11.7
NO-11".pIC–S4 1:< Cr:z;),RLr
J)CCC 1l_D UU-Co •n-in wL-di ic r_.�z<t o,;
Unx:cr Ur
fcr e Lceu c
II.W.of cn=Mploynr Uj)—I IL,Wcvkc'.
tjl,�z.CO?Y of Lk,*, LSrJL-!Of 0115—of for tlx
end U_Lt r:`lum 10 25A Cd MG1,152 can I.--d to 0�-.mr.-%LtjC,''I"-
of a f'u-r of up to 51�00.m )f to r- • •r.1 evil prrultic:in < OF -rA t
Or,-!00.00 L dzy rrv_
ul-
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: / Not Applicable ❑
Name of License Holder:
License Number �C
Expiration Date
*Addresz
ignatur Telephone
Not,A pp licaIb!'l�e
11 9�,Re41ste_ed'Home ate C—
Company
Name Registration Number
Address Expiration Date
Telephone q(/2) 5` Z-':'YJ -
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...... ❑
11 -'Home Owner:Exemption
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. 4 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
r
SECTION 5-DESCRIPTION-OF,PROPOSED WORK(6heckJ1l':ao6licable)'
New House [] Addition M]: Reptacemen�ndows Alterations] [� Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [[] Siding[o] Other[Cl
Brief Description of Proposed
Work: GQ' {._ -)/f'lrj(��Xa)�'s
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa:IfNevif auseand�o"r aclii<iohtezisfiogfiousrtacirco�xglete t :eoTlowing:
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
I
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
s SECTION,7a..-OWNER'AUT#ORIZATION 'TO BE COMPLETED V16HEN
O.INNERS AGENTQFt�ONTRACTORAPP.L1ES'fOR�UILQING:PERMIT." '
as Owner of the subject
property
hereby authorize
to act n my behalf,in all m ers relative to work authorized by this building permit application.
Signature of Owner Dafi
y-r)//7"Cln 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.
Pri ame
gnature of OvlheGA6ent 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 -- -------
Frontac-,e - - ------ ----------- ---
Setbacks Front
Side L: R:'--� L: - R.— — ---- ----
Rear
Building Height -- _ -
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
arkine)
#of Parking Spaces -
Fill:
(volume'&Location) -- — — —A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW O YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW O YES O
IF YES: enter Book — Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 Date Issued:
C. Do any signs exist on the property? YES O NO O
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 O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, grading, excavation, or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 - NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
D'epartrrrsntuse onlyr
' c
City of Nort0ampton ti .ofiP H IL� l
- 'S.` pR"a s✓ �".�..,.-+.ice y'h., ^' �jy✓�f
E�Uilding Department C. CatlO ee it
212 Main Street Sewer a vail�,Sili " ` v
27 Room 100 star a l Avatla6
Ngrthampton; MA 01060 TetsSUa�7ctttral Plans 4
phone 413-587-11240 Fax 413-587-1272 1516 tfSlt
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1.'-St7 E'INFORMATION w
L - TFais sec_t�on to be completedby office'
1.1 Property Address: r _ -
/ /v -? fC✓= J�`- Map _ a Lot U,
� � -
r ,t� OyeHay District
Elm Sf sDistrict �': CB.District 4
SECTION-2 PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
I
Nam(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: `
I-t-h 14,a kl- i fz 0 M haf Z4 f- ' . rat
me{Print Current Mailing Address: 0►oo-z'7j
nature Telephone
SECTION'S.-ESTIMATED.-CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed b permit applicant
1. Building Z/ ®®� d (a):Building PdimitFee
2. Electrical (b>Estimated Total.Cost of
=.Construc�iorr.7rom; 6
3. Plumbing EuildingPermit.Fee-
4. Mechanical(HVAC)
5.Fire Protection
6- Total=(1 +2+3+4+5) Check,Number
Th�s'section For_Offcial'Use Only
Dater,
BuildiriTPermit Nymber: : 'Issued:
Signature:
Building Commissioner/lnspector.of Buildings Date
Y
fr it BP-2009-0875
GIS#: COMMONWEALTH OF MASSACHUSETTS
a ;M &: 177-196 5 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2009-0875
Project# JS-2009-001283
Est. Cost: $4000.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: KEITH HAMILTON 133811
Lot Size(sg. ft.): 9539.64 Owner: DEGNAN JOHN R&CONNIE
Zoning:URB(100)/ Applicant: KEITH HAMILTON
AT. 151 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
17 ORCHARD ST (413) 587-0763 O WC
EASTHAMPTONMA01027 ISSUED ON:412812009 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 2 REPLACEMENT WINDOWS
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 4/28/2009 0:00:00 $35.007733
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo