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DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR '212 Main Street • Municipal Building
North,unpton, MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as hos/her construction sup :,? sor. The stale defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or hvo fame
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 fegulations. 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
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0
F ti ET'43 LIf '-Norf11allip!all _ _-
Qa7 a nth ntr l l e'
o DEPnRTMEIJT OP BUIUJr1\G INSPECTiOlrs
212 Main Strcct ' Municipal Building e
?Northampton, Mass. 01060
«'Orua.IZ'S CONDENSATION LitSURA.NCE AI*FMAVIT
(1i�usxJperm�tCcc)
%with a principal place of business residence zt: -- —
(phone=')
(sat/ci t`r Jstatc��p)
do hereby certify, under the pains and penzities of pegufy, hai
( ) I am an employer providing the followine'workcr's colnocnsaoon cove arc por Im
employees Nvorldng on this job:
(Iasul-:-n=COEI L1) (PoLic:N`u-=ocr) -- (T_:air rior,Dac^)
I am a sole propnetor, general conn-acior or homeowner(tide one) and have hired
the coocractors listed below wbo have the '10B vin wc.;ke Moep_�-auon policies:
/ ."F,ur- _��6 boa/-
0,47amc 0f Conmlaor) Gnsuranc: Compan)•iPo6c; !"'U-M*----) (!-.Ipm uon bate)
(Name of COUG-3clor) Ojis rznc: ComoazviPolk-�, `umber) E.Pt radon Date)
(Na1ne of Con=do;) (Lasuranc Compan)-/PoUq- Namb j) (Exairdoa Da1c)
(Name of Contactor) (Insurmcc Compaay/PoLcy Numbef) kTxpiraiioo Date).
(auac3�s�ocal dcd.ifncccs.a�•cn-cc.'u�info�w..'ioa pc-taisias�n.1!ooc77_c.o:�)
{ ) I am 'a sole proprietor and have no one working for me.
( ) I am.a home owner performing all the work myself.
NOTE:pleu be tw-zm tt'.•"{ }n 6cmcowvcn�.v,o ca play perLoe:w �a '-.:e.wo c rcpair-aric ca a d,.ell-z of
toe Mort then LET-_units in«b�dx ttx bomoo-,v=nz ida or ea the Round+ zppurtcn -tb-- n r_z DO(C=�r.Dy CCcid--od Lo be
cisplaycs unt c the o=:p�m Arc(GO152-=1(3)),:pptiCL600 by n boMwoQacr f=:bc=--_or pamic r=y LL-
lc gsl rtxuc of ea-=Ployx under dre WoCi -C..3;>matio,a Ae(.
I undesta,ad tha a Dopy oC thi,mtcmcm may be for�.urd.ed in tho pcQutmcoe of In&aY.ric!Accdrtj(ffm-of 6a—for the
covcraSc vc irasioa n_-id t1Lt L-iltzc to scauc'covcr&6e unr'�section 23 A of MOL 152 m Ied to the Lmpos oa of aimiaA pc-J6-
cot =a of a fine orup to s 1-�oo.00 and/or is priwomrnt of up to Doe y=cod ci vil pmaPua io ct>-form ora Stop Wort;Ordc and a
fins of S 100.00 1 d_y L&in-d me
For dcq.russll u+c onlr
permit Number
--
>,.2P:—_ Lot
iU c-Mucc —��-
SECTION 8-CONSTRUCTION SERVICES +
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9Re i ' — ° s --•'" `m �.
Not Applicable ❑
1(9 g4eb
Company Name Registration Num er -- —_-
l e CVo.,CR.v e,Li 7 D5
Address Expiration Date
q,S tln W A '-oh Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCE AFFIDAWT(M.G:L,c.162j',,'§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 wonire�.O�erT on-
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
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SECTION 5-DESCRIPTION'OF,PROPOSED WORK(check all applicable)
New House [] Addition ❑:,, Replacement Windows Alteration(s) El Roofing
Or Doors M
Accessory Bldg. ❑ Demolition ❑ New Signs [CI] Decks [p Siding[0] Other[0]
Brief Description of Proposed
Work:_ &ILAA ylL' .440
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a ffpNew'ltartse and uradditia�xfa existEng fiOtxslitg cOr`iateW fiEiAils1,0 W I n,Q:
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 7a-OWNER AUTHORIZATION,-,'TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR'APPLIES FOR BUILDING PERMIT
I, &P Uiy< L/ as Owner of the subject
property
hereby authorize 2� L^I ITIA G a 13xe[,
to act on m half, in al ers relativ work authorized b this buildirtg permit application.
Sign re f Owner Date
I, 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.
Print Name
Signature of Owner/Agent Date
Section 4. ZONING All Informatibli 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 I
I - - --
Frontage ' �-
Setbacks Front
Side L: R:= L: R:'
Rear
Building Height
Bldg.Square Footage �� t %
Open Space Footage %
(Lot area minus bldg&paved I i
parking)
#of Parking Spaces
Fill: °
(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 issue&
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book i j Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Date Issued: it j
C. Do any signs exist on the property? YES Q 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 Q NO Q
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 O , NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
•
y of No#arnpton Stet a xl?e
U ding Department urta '
2 Main Street S+rwer exit ,tt
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oom 1,00
ton;rtha
N MA 01060 Se s sf �ra1?as
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587
h - 40 Fax 413-587-1272 PIoUStt�y 'Tans
V r;1NS ,p60 Ott} rSpeet"fr ��.
AI M O CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION'1.-SITE'INFORMATION
r Thts section fo be cotnpleted:'by office
1.1 Property Address:
d�G Untt
3 e6l
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SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
OM '1 ' M'v-III 0'60vtV1 ell 38q �f����- �� VJo ww�.l�`��► Wl °►°6�
Name(Print Current Mailin Address:
j,ge Hp
(/G Telephone eL
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3.-,ESTIMATED CONSTRUCTION COSTS (j U(�
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 3�0°� (a)Building Permit Fee
2. Electrical (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 For Official Use Only
"','Date ,
Building Permit Number. Issued:
Signature:
i
Building Commissioner/inspector of Buildings Date
389 BRIDGE RD BP-2005-0545
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mag:Block: 17A-280 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-2005-0545
Project# JS-2005-0715
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group Edward T Corbett 119488
Lot Size(sq.ft.): 8668.44 Owner: O'CONNELL MARLENE A&WILLIAM
Zoning URA Applicant. Edward T Corbett
AT. 389 BRIDGE RD
Applicant Address: Phone: Insurance:
1 TERRACE VIEW (413) 584-2546
EASTHAMPTON MAO 1027 ISSUED ON:1113104 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
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• Receipt No: Date Paid: Check No: Amount:
Building 11/3/04 0:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo