06-016 (3) gHAMp � _
Y '
� � �1'rlassachusrtts
DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR '212 Main Street • Municipal Building
Nortliwnpton, MA 01060 e
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CM1Z 108.3.4 to
act as his/her construction sup<:-,,i or. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two farm
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 hour) 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
understand the above.
(Home ner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to Ime.
Date
Address of work
location
r
i
1
04�1W f nTO f
Crib Of '.�Jarilla III P10II
9 r E 3la3 aachntc11 a' —
w v DEPARTMEIJT OP BUIL00\1C INSPECTION'S � —
212 Main Strcct DSunicipnl Building
?Northampton, Mass. 01060
WO1U R'S CO611P ;NSATTO.N L`(SURA.NCE AFFUAVIT
(l;ccasccJpermi ticc)
with a principal place of businessfresidence at: -- --
(phone:.')
(suit/city/ctalrizip)
do hereby certify, under the.pplmi and penalties of perjury:, -hat
( ) I am an employer providing the followine 1worlcer's comocnsadon cove.--S c for my
eluplovees «vor�aig on Oils job:
casusan=ComrzLv (PoLicr Numb-cr) --- (=r,-pirzd6r,D21^_)
( ) I am a sole proprietor, general contractor or homeowner cie one) and have hired
the con-actor's listed belc*w wbo have the follow) er's caE.2oen_saaon pokiest
(Namc Of Con'mcwr) Onsumnc-_ Comp3,i}'/l�Obc-, Num=C;) \J4d o male)
(Name of Conc nor) (Lnssrancc COmoan`'/-POLlc- Nu.mcrr) (%»ir tion Date)
(Name of Coaa-aelo,-) Gnsurajacz CompanyfPabq- Number) (Expimaon Date)
(Name of Contractor) (Insurance Comcauy/Pobcy Numb:.r) kTxpimz6oa Datc).
(aa, _ddicioczl ext:%if ncca_-v to mclud_mfortnAzioa pa-taiains to.11 cvc=-.r_o:a)
O I am'a sole proprietor and have no one woridng for me.
( ) I am..a home owner performing all the work myself.
NOTE:plea be avrarc Lz .j )c 6cmcovvcrs mot,ccuplay pczo=to cb -• c=_ac:jco c nc,au-ark om a E.c11_^ of
Ooc tnc(z th a tlloc t-'Y3 in Wbb ch 1be laomoownc rcxid of oa th.Crvaxa6>apurLcr=l tbee'.n c--c oo(C-,,Zy a-rsdzcd to be
-:aV1Oyea 11D C thek='s c=p--.1im Act(GLIl52=1(5)),ar^ptiation by a boau»ava fcr a Gem_a pczmit tr_y c%idm tl:e
of as crrloyw under thO Wort o(a C ompomacioa Act
I and--_d tha a copy of thin an-. w m„y b.for-nrdod to Lb.Dcq,atmcc¢of Induxiicl ncedcaLd Olfioo of Iar--roc tb.
covens-vcif=ioo and th_t L-ihac to soauc,covRx9c uodc section 21 A of),(GL 151 an Ied to the i= osi6oa of criminal pco-.Wc
coamzvz g of a fine arup to s I,Soo.00 and/or 6=prisoam,ot OCup to OOe ycr and civil pcaaltio in tx form Of-Stop WOrV Ord--and.
fire OC S 1 00.00 a day tpia-A me
For Ecp.nm�u-only
Pcrmit Ntmtcr
Lot
Si cum f iasscc/Pccnuttcr_ j
SECTION 8-CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9�Ae"`stele lc lfomefimroreienEunfracfo , ° M T` " ' Not Applicable ❑
y
Company Name Registration Num er -----..—
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(KG:L.ir.462,,'S 2-5C(S'))
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
r
SECTION 5-:DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors C7
Accessory Bldg. ❑ Demolition ❑ New Signs [C]] Decks [[] Siding[O] Other[a
Brief Desg,{iption of Pro
,posed
Work: f eJ W-:t- s°f c y-4 -
Alteration of existing bedroom Yes X _No Adding new bedroom Yes X, No .
Attached Narrative Renovating unfinished basement Yes `tC No
Plans Attached Roll -Sheet
sa rfi NewKFrarrseDCGOra.ctc�ct>aex>st�nc=(�oasl cl,o-corpee.th' atf� rg:
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 Ta-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT:OR CONTRACTOR APPLIES FOR`BUILDING PERMIT
I, (V^L, An � 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
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 rpe
Sig ture of ner/Agent Date
e I n NING 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 _ 1
Front 1
S ac'ks Front -- i
Side L:' R 1 L:' , R:s 3�
Rear
Building Height
Bldg.Square Footage % i
Open Space Footage %
(Lot area minus bldg&paved �-
parking)
#of Parking Spaces
Fill:
(volume'&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DONT KNOW 0 YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book I Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 , Date Issued:
C. Do any signs exist on the property? YES 0 NO Q
IF YES, describe size, type and location: j
D. Are there any proposed changes to or additions of signs intended for the property? YES NO Q
I
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 r NO
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
a ,
City of Northampton
ing Department r------Main Street ,€� e
3 j i;Room 100
Ngr�t�lt tnpton; MA 01060 uua Se�s��o 5 ra�lar
2phofileY 41} 7'�1240 Fax 413-587-1272
APPLICATION.,J, 'ATRUC ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Thra sectron to be completed by office
1.1 Property Address: i y
(� LOt c Unit
t`lu Ito/i I i go p
ct Mapr
I
1.F Zone Overlay Distrrct
c�IC s��
Erni
SECTION 2-PROPERTY OWN ERSHIPIAUTHORIZED AGENT
2.1 Owner of Record: n L
/� (—
14 v1 V`CIy�L-- lri��lQ � 1 J'JA ��J
Name s7 t) Current Mailing Address:
j i(t 3 S E --Z'��
( L4ij, ff4 ILA't 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 or - (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 q2..Z'
This Section For Official Use Only
, ,Date
Building Permit Number. Issued:
Signature: '
i
Building Commissioner/Inspector of Buildings Date
339 HAYDENVILLE RD BP-2005-0504
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 06-016 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:woodstove BUILDING PERMIT
Permit# BP-2005-0504
Project# JS-2005-0661
Est.Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 43995.60 Owner: THRANE MARY ANN
Zoning: SR Applicant: i r RAKE MARY ANN
AT. 339 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
P O BOX 298 (413) 584-2466 O
LEEDSMA01053 ISSUED ON.10126104 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL PELLET 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: ®1< l o
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occugangy.. � Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 10/26/04 0:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo