17C-170 (2) U�{ttAMP�o Y
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DEPARTMENT OF BUILDING INSPECTIONS �
INSPECTOR 212 Main Street * Municipal Building
Northain0lon, 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 !Js/her construction sulx.:,-isor. The state defines "Homeowner" as, " Ierson(s)
who owns a parcel on which he/she resides or intends 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
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 th ividual trades to secure the permits and inspections as
required can DELAY t e project until such time as the proper permits and inspections are
mad
I, understand the above.
(Ho owner/resident's sigViature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
y
—
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21 2 ?vTr.in Street. .11 1 111 ci}Ia1 13t:1 lllinr° � �• ,
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lcs]i datuc of cn c_J)Ioyx under tLo
I un3cntnnd thus i copy of LhL riatr_r c:-s r.:ay kb Ixw-nrS o:1 to I!n li-ara taxru oC 1ru!>u:n nl Ara 1,�t>'<-'aub of.:=+Ir..'r�o for tlw
oovcragc vciific�liioo and that L•ilurc to can Icid to tl i::7;»Tits t rt^i: l pcnel;:s
dating of a h x of u S00-CI)nr"J Y ir.aui -r�r.-:"_oCup t")e rr}-J e:,I Civil lY]ultics in :cnu oC
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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'Re"tstered Noinelm rovement Contractor:" µ r`°
Not Applicable ❑
Company Name i Registration Number —
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...... ❑
p
�<�^���
11� = ome ®cner.Exempt `on
The current exemption for"homeowners" was extended to include Owner-occupied Dwellings of one(1) or two(2) fami',ies
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 fo-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 per
The undersigned" ome Mies and as imes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, S to ai L ca i " nin, Laws and State of Massachusetts General Laws Annotated.
s_Homeowner Signature c_ _
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all ap icable
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs ( ] Decks [ ] Siding [ ] Otij r
Brief Description of Proposed Work:
*`'7 ""C
Alteration of existing bedroom Yes No Adding new bedroom_ Yes No
Attached Narrative 0 Renovating unfinished basement Yes —No
Plans Attached Roll 0 - Sheet 0
5a. f New hou"se a"rid`or'addition to existing h'oustnP, complete the following_
a_ Use of building : One Family _ .__ Two Family --__ Othtr
b. Number of rooms in each family unit:_ _-- Number of Bathrooms-._ ______—_
c Is there a garage attached?____
d Proposed Square footage of new construction
e Number of stories?
f. Method of heating? —_ Fireplaces or VWoodstoves Number of each
g Energy Conservation Compliance. _ %.ascheck Energy Compliance form attached?
h. Type of construction
Is construction within 100 ft. of wetlands? Yes _-__- No_ is construction within 100 yr. floodplain _--Yes
Depth of basement or cellar floor below finished grade _
i
k_ Will building conform to the Building and Zoning regulations' -__- Yes --__. No .
I Septic Tank City Sewer _ Private well -__-_--_, City water Supply
F ECTION-7a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN
WNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
_ �� �? --- --- --- -- - - — as Owner of the subject pr p� t�,
hereby authorize
my behalf, in all matters relative to work aWhorized b, .h n< <r-rit app"ication.
Signature of Owner _Q Date
— ---------- ----
as Owner/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the best of Amy
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent _ Date —
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF 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
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
arking)
# of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO
__Z_ DON'T KNOW _ YES —
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page arid/or Document #
B. Does the site contain a brook, body of water or wetlands? NO _ DON'T 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 X
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: __ __
° ^Departrpentkuse onl
d �l �& �ndT�F
City of Nor thanipto Status:of Pe m �
trig Dep�:!tment Curb G w
utlDnveay Aernit�
" a'f s a
2 Main Street Sewer%SepticAvallabfltty k �
A Roorr1 1�0 �Wate>lWell Avatlabilftyr ' t
I "r l 1 (1
j"Z fJ f t1 pto i. f� A G � Two, ets of Structural Plans��
1 Q 2
1�- 1 C`�-0 f lix 4 J .? .,/ !Plot/site, Pall$
i Other Specify
I SPE�5 �- -
Q NSTRUC , ALTER, REPAIR, RENOVAT+= CR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
This section to be completed by office
11 Propel ty Address: c / n
P9ap ---1-�5� Lot r7o< Unite—_.----
. —�- ------- - � -----._..----_____ -
• Zone---- Overlay District
Eim St. District_ CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGEN 1
2.1 Owner of Record:
_ _ �34 S
2.2 Authorized A,ent_
i
SECTION_3 ESTIMATED CONSTRUCTION COSTS
---------------------------
�stimated C c st Official Use Only
_ completed nv
� idir�g /� �� E3ulding Permit Fee
„a Total Cost of
--+
-- ---- _ -- �---____------__-_ - c nstruction from (6)
Buiidina Permit Fee
i I
�_ r iE Prot ton
? rcn urrb r � 4 _
5j
This Section For-Official Use Only
Building Permit Number:_ +� _ ___ Date Issued:-_--,_
Signatwe:
Building Commissioner/Inspector of B r irlmgg, r)a'e
File#BP-2004-0070
APPLICANT/CONTACT PERSON SURGEN PAUL C&LOTTIE B
ADDRESS/PHONE 34 HIGH ST
PROPERTY LOCATION 34 HIGH ST
MAP 17C PARCEL 170 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction: REPAIR ROOF DAMAGE&REPLACE FRONT STAIRS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commission
-/� /4 7-21,613
Signature of Building OffitAl Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
4. � BP-2004-0070
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0070
Project# JS-2004-0105
Est.Cost: $4000.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 14069.88 Owner: SURGEN PAUL C&LOTTIE B
ZoningURB Applicant. SURGEN PAUL C & LOTTIE B
AT. 34 HIGH ST
Applicant Address: Phone: Insurance:
34 HIGH ST (413) 584-5137 0
FLORENCEMA01062 ISSUED ON:7121103 0.00.00
TO PERFORM THE FOLLOWING WORK.-REPAIR ROOF DAMAGE & REPLACE FRONT
STAIRS
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 7/21/03 0:00:00 2368 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo