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DEPARTMENT OF BUILDINO INSPECTIONS
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INSPECTOR '212 Main Street • Municipal Building
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNIR 108.3.4 to
act as his/her construction sups. "isor. The state defines"Homeowner” as, "'Person(s)
who owns a varcel on which he/she resides or intends to be;-a one or"twoJWW9 -
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 u ng deparhment for the City of Non"pton Wants-airy person(sj-who-see -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 fegulations. The inspection process,requires that the building department be called
to inspect work at various stages, which include_foundation/footings(before backfilI),
sonotube holes (before your), a rough building inspection(before work is
concealed) insulation inspection(if required) and a fmal 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-roe. _-
Date
Address of work
location
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DEPARTIvfEKT OP BUILDr.\,G INSPECTIONS -
212 A4ain Street Municipal Building '
Northampton. Mass. 01060
«'OR1 CR'S CONI OENSAITO-N 'MSURA.NCE FMI AVIT'
(1,ccnscrJpernvttrx)
%IVIth a principal place of busioessfresidence at: - —
,L,S k A los3
(=cucity/staLezip)
do hereby certify, under ttie.p?ins and pen2lties of per3w y, hii
O I 2m an employer providing the following N- ori:ct✓s comocnsa:io, coven^e for my
employees working on ilus job:
(Laser-mac Coax. v) (Polio;Numb-cr) (Expir-a or,Dam) '
( ) I ain a sole proprietor, general contractor or homeowner(c c;e one) 2nd have hired
the consactors listed below wbo have the folloiviog worker's col oen_sa6on.pokier
(mane Oi Co'C^cwo Onss!rzincc CoinpanyPtouc D:Itc)
(Name of Conmctor) Ras-lran= Comoaa}vPolic Ntmb-c-r) (Espiruon Date)
(Name of Coaaaao:) (Insurance ComT=yfPolicy N:1mbcr) (Expirtios Date)
(N2.me of Contractor) (Insurancc ComcanyNoUcy Numb:.r) (Eapiratioa Date).
(atuc�t:d�tooJ s:x�.ir een_L-ti•to cue inror=Lidoa pe:ta,iain6 to.Il ooc-tc�)
(Wi.am a salc proprietor and bave no one woridng for Ire.
( } I am:a home owner performing all the work myself-
NOTE:plea be Lvruc it=kite bcc=o%na-a wba c ploy pcam ro c==-=Qc cr rcp2+r-=tic oa a d-21_6 of
rux molt then L--v�-gilt is utuh Lb.bomwu=raid=ec oa the rTa,,4.zp7zrt=_++tbero=wt C==-.1}y coed--d to be
c-ploy—uar±�the"` —=P— —Act(G L1152-=1(5)).:ppliaxaon by a bommaac fe a Gc=c or pe-mit==y e%•idmne the
leg!C-. of e.a c=:Ployer under dao Wottela CooVo=a;oa A.L
I uodestaad tha a-0"of tbi.catemm2=.y b.foe-,-d.d to the pepa(taacat otIocicsri.l A",&.ze Oaj_or LzMW aa•for th.
c O`cr o^e vC'i Cam*d Ma f dcm to teau tovcrmse umdc%0=20a 23 A or MOL 137 ca l=d to the unPosidoa cf eiwi ptss316cs
sxg of.rime or up to S 1X00.00 arNor 6MPrb4=5CCj oCtp to one yt=r earl cNil p.-?ti=iu 6c form of a Stop watt Ord--and.
&m of S 100.00 t day.pica me '
Fa d, J U, only
SECTION 8-CONSTRUCTION SERVICES J
81 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
` �teret�onte�lmpra�reriFre��;anY�to �� ,:.�... --
1 X7 0�
Company Name i Registration Number -- ---
Iy
Address Expiration Date
1.z 0 Telephone
SECTION 10-WORKERS'COMP-tNSATION 111ISURANCE.AFFIDAVkT`(M.G:k..C' F52,..§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 buildipt permit.
Signed Affidavit Attached Yes....... iV. 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 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
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check alhaaplicable►
New House ❑ Addition ❑; Replacement Windows Alteration(s) ❑ Roofing
Or Doors Cl
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [Q Siding[p] Other[[D]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa f€[Vey a se a �i �if£cn fa fsti l: ious�n�nor ii e wi,6 'a. "tna
a. U^"of build'^^.One Family Twn 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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TQBE COMPLETED WHEN"
QWNERS AGENT OR CONTITACTOR APPLlit Ft R BUILDING PERMIT
I, 3 M t0 / 1,16d at/sine as Owner of the subject
prope
In eby uthorize
t act n my behalf ' all matters rel tiv to rk authorized by this building permit application.
./ c
Signature of Owner Date
as Owner/Authorized
Agent hereby declare that t e 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.
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Signature of Owner/Agent Date
Section 4. ZONING All Informatibti 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
Side L: R L: R:'
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved --
parking)
#of Parking Spaces
Fill: r I
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW Q YES 0
IF YES: enter Book j Page a and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
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 0 NO Q
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 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 tP Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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City'of Nortf ampton eta 17ertrt�
�i Bu,jWng Department cu v w
212 Main Street ee tr 6w -
Room 100riFe�
Northampton;AMA 01060
phone'413=587-1240 Fax 413-587-1272ottSktesansre
Te PUMP
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION:9 -SITE INFORMATION
This sectrort to be completed'byoffice ''
1.1 Prooertv Address:
40) T1
S'f' 0('a^^4-4_
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EOverlav,rDrs1rrct'
Errrrst ni5trt ce oistrrct
SECTION -PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 OwnVvf Record: _
ST 41 �5 Kp pot. tS
N e(Prin A Current ailing Address�•±- q 8g
V.S 11, fef Telephone
Signature
2.2 Authorized Agent: /
,nv .l Lv c � fox Lr-L)5. �'1,���v
Name Current Mailing Address:
(3 - -3 �
Sign re Telephone
SECTION 3 TIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical W (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-176r Official`Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2007-0197
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2007-0197
Project# JS-2007-000301
Est.Cost: $4700.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group TIMOTHY J LUCE 149288
Lot Size(sq. ft.): 20952.36 Owner: SHEA TIMOTHY E TRUSTEE OF THE
Zoning.URB Applicant: TIMOTHY J LUCE
AT. 163 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
P O BOX 14 (413) 387-9800
LEEDSMA01053 ISSUED ON:812212006 0:00:00
TO PERFORM THE FOLLOWING WORK:REROOF PORCHES
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 8/22/2006 0:00:00 $25.00398
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo