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DEPARTMENT OF BUILDD\1G INSPECTIONS J
INSPECTOR 212 Main Street • Municipal Building '
Northampton,MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as hds/her construction sup,:-,•i sor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be,"a dne or two fami --
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 roueh 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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Part ljL4)1>PtoI'll
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c� DEPARTMENT OP BUILDr>\,G INSPECTION'S
212 Main Strcct Nluniclpal Building
a
Northampton, Mass. 01000
WOR.ICCR'S C0I1II'ENSATTON MSU ZA-NCF Al,I'D�A.1TI7-
I, `J cJ
-
vllth a principal place of businessfresidence at: --
r--
3—(� (Ph 0nc') .306 011 7/
do hereby cerdi ,, under dic.pw' Ls snd penalties of pcgury, :hat
( ) I :ten an employer providing the follo%vine'workcr✓s coinocnsat;o, cove age for Iny
employees wortang on Oils job:
I
(Lnsuranc Conra.m-) (Potic-.Nu-ter) --- (T:•piratior. Ds)
O I am a sole proprietor, general contractor or homeowner(c c:e one) and have hired
the contractors listed belo«r wbo have the 1jolio%vi9g worker's Ca=oen_saaon pokiest
(Nblue Of Contmaor) (Instranc Coinpany t�obc-i Numb—) (E')Mauon Datc)
I
(Name of Coau-mor) (insurance. CompaayvPol cn, \Lunen) (Lau it lion Dzte)
(Nzme of Contractor) Onsuranc-- Compan}•/Pot;q- N Lmbtr) (Exaim600 Datc)
(Nzmc of Contractor) (Lasuranc-- ComrzQy/Poticy Numb_r) (Expi z6oa Datc).
(a[I]1,31.`-ddY:OC�t bcd,tr CCL�CS+•'ti'in mctiu(�laror=&7on p=,l L ixxc b ate ooh--GO:7I
it
am a sole pr-opnetor and have no one worming for me.
1 ( ) I am,a home owner performing all the work myself:
NOTE:pl=s be tcczrt Lc ,'tJe lxmrsMVm.x-bo ernPltry PC7%- s to r rtPair-Oric o c d.•ciL•a or
I not meet th:a tt rrr r�i�is� �the bomoo+*ver rced�or oo the Qwaca zppurtenri tbeco r r ox E-r _l}y oeced w be
eziployc s unc a thew ocM?=--e;ep Act(GO 52,a 1(5)x,zppii=Eoo by a bomco as ref a lid_cc paxaa r=y e.-i&=the
Iegs rwx.or .n&,tho Worirclr �
I
- [uadeztand tha a ooPy or Chia eat.emna m.y be roc--,Led w tbo Ae a—&OIIioa or Iru—roc the
cov xFc rairelioo and thct r_ihae to seaut bovtrase coder soe oa 25 A or l.(QL 152 na Ion to the iazaos--or cimiasl pcc-ttic
=;o ora fiat or UP to SI-�00.00 and/or m�i or up to ooc yuc tad a%il pmw.hio io 6r room or Stop Wort;Ordcr and a
Gm or S 100.00 a d.y rpinsl me
For u-only -
7 ._.. Peron Numbcr
?.dap.. -- Lot "
i it—Umt Lt=IS0j caniucz Date J
SECTION-8-CONSTRUCTION SERVICES ±
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
e Not Applicable ❑
Company Name Registration um er — --
—5 (, �IYnocle S1 Z,! o/y G
Address Exton Date
Telephone '57's
SECTION'10-WORKERS'COMPENSATION:INSURANCE AFF,IDAVfT(M:G:L.c.152,;§25C(6)j
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...... ❑
M5 47
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 1083.5.1.
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 be/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
i
t••
SECTION 5-DESCRIPTION OP PROPOSED WORK(chec 'alfapplicable�
New House ❑ Addition ❑:; Replacement Windows' Alteration(s) Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding[O] Other[�]
Brief Description of Proposed, ^ - /t
Work: ._6tJ�� l 14((- `'L[/1�.c4�ra lG2 c- fit+
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
� °y=am"-rte^' a'.� +a�.�c"m,.„-.��°F, ,n, .,- ^.�a� .•",�..�-��a:sw r� -^.-Ev,y�„"^'�„`�-.,,,
s'a feviiosand-ai#io #oex�st�nct Ciaslng..,comateter#�ieolfainQ:
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 J 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 FOR BUILDING=PERMIT
as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
77-------------------------
�� ! v ,as Own u� orized�)
AnTbe hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my
elief.
Signed under the pains saand
penalties of perjury.
� r✓ (�l_J �� r-,��C t
Print Name '�`�r.�'��
t U
Sig atur Own /Agent ate
Section 4. ZONING All Informatibh 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:..�J R:' I L:' ; R:i
Rear
Building Height "F
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking).
#of Parking Spaces
Fill: j
(volume,&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES
IF YES, date issued:: �
{
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES
IF YES: enter Book j Page; and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T 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 0
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, describe size, type and location: i
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.
� - Y,of Nortoampton
building Department
C5 ,2 t 'Main Street
JUN 7 20 Rpom 100
-
Northam ton; MA 01060
.y
L.. r ;lone.41 X587-1240 Fax 413-587-1272 a
sc
_ APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed by office
n a
t F • R
done ` O�ea 'Dlis rECt
EIm,St Disfr�ct ' `�� ,�� �CBvDistncf fi h:
SECTION 2--PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
►C'iL �'i �3'
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: A Q!G
Name(Print) Current Mailing Address:
Sj " ture Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical fb}.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) �� f i Check Number 1p oN
This Section For Official Use Only
Date,;
Building Permit Number Issued:-
Signature: r
l
Building Commissioner/Inspector of Buildings Date
340 BRIDGE RD BP-2005-1222
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.-Alock: 17A-288 CITY OF NORTHAMPTON
Lot: -001
Permit: BuiidinQ
Category: BUILDING PERMIT
Permit# BP-2005-1222
Project# JS-2005-1640
Est. Cost: $828.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq. ft.): 18774.36 Owner: FITZGERALD HAROLD R
Zoning: RR Applicant: John Corbett
AT: 340 BRIDGE RD
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON.619105 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL 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 6/9/05 0:00:00 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo