17C-174 (3) �I 833A[1tIlStttD
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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building s •`�
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as l.is/her construction sups.•,,ssor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fam—My
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 oven construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and r',egulations. 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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Ili W o DEPARTMENT OP BUILDrNG INSPECTION'S
212 Main Strcct ' Municipal Building
j Northampton, Mass. 010GO
«'ORICERIS COI T ENSA770N L`iST- A C'F Al, 'U)AVl-T'
l ,
'; (li c�vs�^rlpermi tttx)
\%rith a pruicip place of businessfresidence at:
I I�►�T U9r,hone=) �t-4
s>�uci /Stalcln
( r7 P)
do hereby cerzifj,-, under thc.pauLs and penalties of pegury., -hat
j ( ) I am an employer providing the followmct workers coinocnsaoon coverts for 1ny
etuplovecs wor>ong on this job:
i (Lasul---n=Comrauv) (Policy Numbcr) --- (r:-p)ratior, Day)
( ) I am a sole proprietor, general coomacror or homeowner (ciu cie or2e) and have hired
the c000-actor's listed below vvbo have the fokwinQ worker's co:ii:)tnsa0on pokies:
I --
(i+tllll: Of COn!::?CiO:I (II1R!mnc:: Company/PoUci Nfurn r- D'Ilc)
(Name,of Contractor) (I.nSIl=Cr-. COMIMM-170UM• Numc_r) (Exp6:_6on Date)
(Name of Conuacto,-) Qnsuranc-- Company/Pol;n• N,tmbu) (1=--�:pim6on Dalc)
I
Game of Conc actor) Gnsuranc-- ComranyNoLicy Numbbcr) (E��irtuon Darr).
(n¢ar31 ati'!i�oca!s3cc irac,r _-�•to -nrorma=ioc pciniai to.D ooa:7c.con) .
1 ( am a sole proprietor and have no one worl;3ng for me-
} ( ) I am>a home owner performing all the Nvork myself.
NOTE:pie=be aware Cfii w•t J bcmca+vm''bo mzPloy pczooa to
amt QTOeL th-- tbr—c-aeu to tom. ell ul)e botnartroet rvsd.,IX cc the IIwzi6 l�pV.[tL'p-'i1 SI1 ao wr OCK C-.._H.:.-Uy C0=6--=6 to be
cr*cycs Ur)?--the Nis cam..==xica Aa(GUI 5Z=1(S)�s.pplinaoa b-y n bomwaaa f=:Ge=_(x permit say"dma the
Icgl ctayc of ea c=ployer under tho Wa i el comgomatioo,la-
I u-derztaad d-a O,py or tbi.c -=..a may t o focv.njded to tbo D,cgartmaos of lnd,arricl A,ac i'Otroe of 4sr++�+oor+ror tb. _
town sa vxrMerica and dta Utac to s4o=)covcrnSc tmdc sociioa 23 A or hiC)L 151 cna ted to the imposition oI aiminal Pcailsio
ooasismg of a tint of up to S 1.500.00 and/or imprtwmnd or up to ooc yuf e.od CiVU pcaatua is tb'ram or a Stop Worti of `�a
ri=0C.1 100.00.day tpiast t>w
Lot
Pcrmlt Number
l of Li crmiucc e j
SECTION S-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
' ere Mmeu p Me rneoiitra o Not Applicable ❑
Company Nobe Registration Num fi— r--- -
Address Expiration Date
c/
A ���5 Telephone /n
SECTION 10-WORKERS'COMPENSATION INSURANCE"A1rF1DA1/dT
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...... ❑
iv,
.
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 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 WORK(check alhapplicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[O] Other[C:�
Brief Description of Proposed �` 1Zytl
Work: V
Alteration of existing bedroom Yes -- -Iqo Adding new bedroom Yes
Attached Narrative Renovating unfinished basement Yes
Plans Attached Roll -Sheet
fat ifousesin ci�iQiruf xls#m na �oimplettheallnaitrul:
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.-OWNEWALI THOR17ATION TO BE COMPLETED WHEN
.-OWNERS AGENT OR CONTRACTOR=APPUES:FOR BUILDING PERMIT
cnry as Owner of the subject
property
hereby authorize 1 c`uG► CC �• ��
to act on my behalf,in all matters rel tiv to work authorized by this building permit application.
Signature of Ow er Date
as Owner/Authorized
Agent hereb tare 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 Na
i j ;_
Sig of 2.v&4YAg4nt Date
Section 4. ZONING All Informatioh 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 j j a
Side
Rear -- -�
Building Height
Bldg.Square Footage %
Open Space Footage __ % ;
(Lot area minus bldg&paved
f
parking)
#of Parking Spaces
Fill: r #
volume,&Location
A. Has a Special Permit/Variance/Finding eve en issued for/on the site?
NO DONT KNOW YES
IF YES, date issued:-��
IF YES: Was the permit recorded at the Regist f Deeds?
NO 0 DONT KNOW YES 0
IF YES: enter Book i Page; and/or Document#I
B. Does the site contain a brook, body of water or wetlands? NO DONT 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
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
IF YES, describe size, type and location: j
E. Will the construction activity disturb(clearing,grading,excav 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 Nortoampton
,Building Department
212 Main Street
C`o Room 100 k.,
NoAampton; MA 01060 � :t
413-597-1240 Fax 413-587-1272
AT 1`0 O 6NSTRUet.ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECT ON 11=.SITE.INFO,RMATION
Tins sectiod to�e cotxttedby offuce�a
1.1 ProaertyAddress•
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SECTION 2-PROPERTYOWNERSHIP/AUTHORIZED'AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address: QQ
Telephone
Signature
2.2 Authorized Agent:
�)o p c 1`� 1.rze•�� Cat 0)
Nam ) Current Mailing Address:
'Simfature Telephone
SECTION 3 ESTIMATED-CONSTRUCTION.COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ]7/C (a)Suilding Permit Fee
2. Electrical 4(b)5sti rnated Total Cost of
Construction from 6
3. Plumbing .Building Permit Fee-
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 0 42 Check Number
This Sectlon�For Off cial'.Use Only
Date'
Building Permit Number sued:'
Signature: ► .
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Building Commissioner/inspector of Buildings Date
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22 FAIRFIELD AVE BP-2006-0090
GIS#: COMMONWEALTH OF MASSACHUSETTS
MW:Block: 17C- 174 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2006-0090
Project# JS-2006-0128
Est.Cost: $7100.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DOUGLAS LUCE 139057
Lot Size(sq. ft.): 5314.32 Owner., ANDROS DOROTHY
Zoning:URB Applicant. DOUGLAS LUCE
AT: 22 FAIRFIELD AVE
Applicant Address: Phone: Insurance:
122 AUDUBON RD (413) 584-8786
LEEDSMA01053 ISSUED ON:7126105 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: Date Paid: Amount:
Building 7/26/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo