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DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR '212 Main Street • Municipal Building ',o�44
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supr.-,Pi sor. 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 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
1, 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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A_ � � j�a7 anll�RL[tta'
4 p DEPARTMEIJT OP DUILDDIG INSPECTIONS
212 Main Strcet Municipal Building
Northampton, ATass. 01060
tic ORICE R'S C O YTP E N S A'n O lei M S URAN CE A 17FD)A TIT
(7i ccnsxJpc�m�tfcc)
v.ritl_i a principal place of businessfresidence at: -- -
(phone-')
(SUc--t/ci ty/sLucia P)
do hereby cerdfy, under thc.paias and penalties of perjury., :hat
( ) I am an employer providing die follo%vinL'%vorkcr's comocnsario, cove Mgc for Im
emplovees wortong on this job:
(I>�cuJ-_n�Conn:=c�•) lPclic:?�u.�r) ---. (r:-pir<uor,Dzt`}
( ) I am a sole proor,etor, geoeral contractor or homeow-oer (c cie one) and have hired
the coneactgrs Lsed below who have the following worker's c ��en_uaon pabcies:
(1143mc Oi Conmictor) Gn iiranc.; Coinoan)-ito6c{ !,,I=hCr) -- �`:>lidt?on Ditc)
- (N me of Concmaor) (Insufancc. Compazw7oiev `uncrr) Date)
(Name of COa=ci0;) (Insimanc; ComTan}-/POUq- Namb r) (Exairdon Daic)
(NzMC of Coulmaor) Unsuraac-C Comcauy/Policy Numb,:.r) (Et.pirn,6oa Datr) .
(nII.i3:d.'!i:;oc�-I txC,if ncc�.�-w ax?ucL infonxv�-1oo pctn�to.0
{ ) am-a sole proprietor and have no one wor4dDg for me.
( I am.a home owner perforTaing all the work myself.
NOTE.plea lx ntrzrc Lb,: t ]e hemeo.�vcr3 u mil%pc-.c=w d.o or rryaII�ork=a d%,TI of
aDC mot th_-t!s---tmfi is tc-y�the bomoowne•r=do«eo the p-cucr p7artca==tbcr-o Lr out Cz=r=Uy occ:d.-•ni to he
citploy-- thc.tiaid c==pu-caA=(GUI 52s1(5)1 by tX-'T y
n^ptiaboa n bomcoa-oa for c lice=a r1_ ctiidmoc tLc
Iegal rt.aai<or—cZ7loyoc under tiro Wo,i ,Compom.yioo.Aa-
[uadcztand thin a ooPy of thi.carcmari o y be f----id to tho D,,,—.,ar Aaod—s'Offioo or 4 ir•no^for tb.
covaz�vmretioa nad Uu L•i1L-c to 14cuc bovcrnse undo Iciioa.23A of}.tQL 15*1 ew Irk to tha i=pOSIIioa o(cia ival pcatltic=
coaiaza of a riot orup to S 1}oo.00 oi-wcr iapri—=orup to ooc yor Lod 6.43 pca Yum is 6,focal or.Stop Work Or'dL aad a
fig o(S 100-00 a d_y apja-a me
.. For d,,-, 1,t u—only
/J Pcrmll NUIDbC1
hen Lot '
Signawrc of Lia=iscc/Pcrtniucc e
SECTION 8-CONSTRUCTION SERVICES- t,
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
3"Rebistere7 fCoirie imiiravern2nt Eontra�tor Not Applicable ❑
Company Name Registration Num er ----"-"
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-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 an ocal Z g 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 Alterations) Roofing ❑
Or Doors 171
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[0]
Brief Description of Proposed
Work: /N r /�F-a
Alteration of existing bedroom Yes ✓� No Adding new bedroom Yes ✓ Nom'
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6 {f`Neva% ouse`and tr dd[ft ex><stincr ousint cori,p eteA,v,of dWif�g:
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.
1. 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, 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.
i
Print Name
i
Signature of wneOAgent Date
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Section 4. ZONING Al I Informati6h 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
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bidg&paved
#of Parking Spaces
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A. Has a Special Permit/Vurunce/Fndi ever been issued for/on the site?
»r� '
NO �~�~�� DUN7KNOVV �_� YES v�� -
IF YES, date issund:
IF YES: Was the permit recorded at the Registry of Deeds?
��
NO �� DON'T KNOW 0 YES
IF YES: enter Book Page and/or Ducument#'
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�� �� ��
B. Does the site contain u brook, body ofxxatarorwedands? NO �~/ DON7KNDVV v~~� YES v��
IF YES, has a permit been or need to be obtained from the Conservation Commission?
'
Needs tobeobtaloed *°~� 8btaioed v�� Date
�~� x~_� ' '
C. Do any signs exist on the propert �� ��y? YES x_� NO �~�
IF YES, describe size, type and location:
__
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre oriod part nfo common plan
that will disturb over 1acre? YE8K`_^) NO K~_~)
�
|F YES,then a Northampton Storm Water Management Permit from the DPW iorequired.
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N� l�ortha pto ; MA 01060 FSestStrtcralE[an � � �
phone 413-5 1240 Fax 413-587-1272 PtotkSlte 'tans y , � C g
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PPLI 1G)1J.:6 ` NSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section o be comptetedby office
1.1 Property Address: _
��
�f TU J 0106�z- Zone Overlay,Dtstricf
Elm S�Distract °� � -GCB District � .
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name P' ) Current ing
//z/1
Telephone
Signature
2.2 Authorized Accent:
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)
5. Fire Protection 1;,r C7��
Number
6. Total=(1 +2+3+4+5) Check _
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
i
Building,Commissioner/Inspector of Buildings- - Date
88 HIGH ST BP-2005-0606
GIS#: COMMONWEALTH OF MASSACHUSETTS
Ma p-Block: 17C- 154 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-2005-0606
Project# IS-2005-0307
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.): 13590.72 Owner: COHEN EDWARD N&
zoning:URB Applicant: COHEN EDWARD N &
AT. 88 HIGH ST
Applicant Address: Phone: Insurance:
88 HIGH ST (413) 585-9326 O
FLORENCEMA01062 ISSUED ON.11/17104 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: C/(' /l-3Q- C
THIS PERMIT MAY BE REVOKED BY THE CI Y OF NORTHAMPTON UPON VIOLATI F
ANY OF ITS RULES AND REGULATIONS. '
Certificate of Occu an Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 11/17/04 0:00:00 915 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo