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DEPARTMENT OF BUILDINTG 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 has/her construction sup,_.,'ssor. The stale defines "Homeowner" as, " P erson(s)
who owns a parcel on which he/she resides or intends to be,a one or two fant:irr-
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
' T /�2/� understand the above.
I, Jo t�1.nl 1J � D
(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 ( b
Address of work
location
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BL� ���v�� MA
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toamchnsrlla* —
II W DEPARTMENT OP DUILDr)\'G INSPECTIONS
212 Main Strcct Building
j ?Northampton, class- 010GO
` 'O'RJ ti IZ'S CO NQ'1✓N S ATIO.>�I G` S UT t� CE All
(I1 CCnS�j)C7TI7J t1CL)
principal place of businessfresidence zt: -- —
(s> t/aty/st=/Zjp)
do hereby certify, under the pains and penalties of perjury, --hai
( ) I am an employer providing the followine!workcr's cornncnsn io, covem�e Cor my
eroplovccs vvorUng on tills job:
(I�sira Coma-) (Polio: Nu mber) (c:-plm on Date)
(141I am a sole proor,ctor, generai contractor r =hoimneo�wvoe- ccie one) aDd have hired
the coauaciors listed below wbo have the ',oUo%Vino worke>'s compep--taoon policies:
O IV E
(Name, of Co:1t^Cior) (InRranc;: CoI pan)Ylio6c,- Gate)
(Name of Contrzaor) (lnSlaranc: CamDaZN'/POIjC NUMn Cf) (%xDimiion Date)
(Name of Coturaao;) Qnm>_ranc: CamP=)-[Pot;cy Numb:r) (Expimdon Dam)
i
(N;--Mc of Contractor) (L=ra.nc-- Company/Pobcy Numb`r) (E.xp s-,ion Date)_
(aaac'r-1di'i0cal rboC,tf ncc�--v to aidu&iafort3,.7oa m
P=IAim c to.11 coca--i=n.�) .
O I am a sole proprietor and have no one working for me.
( I am.a home owner performing all the work myself.
1
jNOTE:plea=be cw-ue tf`••.4jjc .to cmPlay pc-com w L�o •:, •••_ =—.:wao r rc;aa work m L d%,, :-Z of
i aat more tb_a L:---taai'j to vinch the bom.,--wr n.=da oc oo Lb..QouD6 i,7 • tbCCO LT nX Cca .UV cc- :&,-cd W LC
eiiploy=1, the.«�-o=p,--,-on An(GL4 52-=1(5)�=plicL6on by a bomcoQaa for a Gam_or permit n_y nid� the
Ic-6s3 ct-- of t_o cr.Ployx under dr.o 17lwkt -t Coosgomttioa.AoL
I
[uadcn.wd tha a Dopy of thin mtcmoa may be foc-xord.d[n tbo pcportmo�a of In�s.rW AceAc Off o0 of 4a+nnce or tho
oovar.Sc vcrir�t=zioc and the L•iltac to Lo==)overuse uDdc soaion 23A of?,((DL 151 can Iad to the iaapos2ioa of criminal PciZiltic
ooasisixg oft Gx orup to S 1300.00 and/or�isoo�of up to Doc yc3r tad a%-il P=Ikja in L5c form of a Slop work or'dc and a
rim of S 100.00 t d_y tpia-A
For 6�a+tm='1 u,c mty
1 pcf=,I 1`l ttIDt�CJ
Lot
Sign turc of LicQiurJPcrmiucc
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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
9 2eaistere�` tr► -oritraclto Not Applicable ❑
ome oroveme
Company Name Registration Num a— ----- - —
Address Expiration Date
Telephone
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...... ❑
;
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-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
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SECTION 5-DESCRIPTION OF PROPOSED W..ORK(check all applicable)
New House [] Addition ❑:, Replacement Windows Alteration(s) Roofing ❑
Or Doors E3
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[10010
Brief Description of Proposed
Work: l-.LL-Pli-- AN-D I-WK UP E x151- NCB L--30oJ 5710 VLc
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes No,
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa-li l�ew.house an dd�t>o eexis#t�ra io stiig omtzls a?fi a oltowinc
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 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 8E COMPLETED WHEN
OWNERS AGENT.OR CONTRACTOR APPLIES FOR BU(LDING:PERMIT
1. 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
1, J b Cd,\) DILL/-{0 D as OwnedAuthorized
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.
Jo H ,y D i&.4-1w-D
Print Name Al V 10 12-
Signature of Owner/Agent Date
• 'q4
Section 4. ZONING All Informatihh 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 — r---:
Bldg. Square Footage —; r--I
i
Open Space Footage %
(Lot area minus bldg&paved
parking)
x
#of Parking Spaces
Fill:
(volume I&Location) i
A. Has a Special Permit/Variance/Findin ever been issued for/on the site?
NO 0 DONT KNOW YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW YES
IF YES: enter Book Page; and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW YES
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 NO
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:
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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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City of Nortf;lampton ;
Building Department
212 Main Street
Room 100
Northampton; MA 01060
phone 413-587-1240 Fax 413-587-1272 �'totfSit
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
�� fiAalx Lot Unit
Ft-o to j Gc Zone Overlay Dtstnct
/ �Elrn SL'Distnct • ,CB,Distnct -
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: _
Name(Print) Current Mailing Address:
411 sue--!I 5
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature 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 (b)Estimated Total Cost of
Construction from 6
3. Plumbing --- Building Permit Fee
4. Mechanical(HVAC) —7
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For-Officiai Use Only
Date
Building Permit Number. Issued:
Signature: -•�- r /�orr�.
Building<Commissioner/Inspector of Buildings Date
55 OAK ST BP-2006-0428
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-278 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:woodstove BUILDING PERMIT
Permit# BP-2006-0428
Project# JS-2006-0631
Est. Cost: $40.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 12240.36 Owner: DILLARD SHANNON COKER&
Zoning:URB Applicant. DILLARD SHANNON COKER &
AT. 55 OAK ST
Applicant Address: Phone: Insurance:
55 OAK ST
FLORENCEMA01062 ISSUED ON.1012112005 0:00:00
TO PERFORM THE FOLLOWING WORK.-Wood Stove
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:D K //—l?. O
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND 7,1z;*tSiEn:atu:reL: -7����
Certificate of Occupancy
FeeType: Date Paid: Amount:
Building 10/21/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo