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DEPARTMENT OF BUILDING 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 l:is/her construction sup,:: .-isor. Tlie state defines "Homeowner" as, " Person(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 baekfill),
sonotube holes (before pour), a roueh 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 ch time as the proper permits and inspections are
made
G _
I, understand the above.
(H me wner/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
(rii-�3 of
A E c}ZaaaAcllnrc11s' -
DEPARTMENT OP BUILDr\IC INSPeCT-)01.'S -
212 Main Strcet ' Municipal Building
Northampton, Mass. OIOGO
' WOMCCR'S COnUENSATION MSURANCE Al,
L,
i
(li cr�permi ttcc)
\311ith a pl", 'pal place of busioess/residenee at:
_ (phonei.
� (sarJ..t/ci t7'/stab./a p)
do hereby certify, under the.paim and penalties of perJury; hat
( ) I am an employer providing flit followino- �voriter s coinocns-n:io, covemSe for Iny
eluplovees worlong on dies job:
s
C�s�'=nom Conn ) (Polio; Nu- r) -- (T rpirzi or, Dzit)
O I atn a sole proptetor, general contractor or hotneoW-0 (c dz ore) and have hired
the conu-actors listed below wbo liave the follo��ring worker's comoeri_s2don policies:
I -
(i+amc Of Cont^cior) (In umncc Coinowi •/lloUc'i ?gum*__ (EX:)I Ju^n DitC
f
(Name of Contractor) (Ins-draoec ComoaMv/Pok— NU= cr) (ii-Pir,uoo Date)
(Name of Contractor) (Lasurac= Compa-oylpolicy Numlu) (Expirtien Datc)
(Name o!Contractor) (lasuran� Comrany(Policy Nttmbir) (Expirdtioa D ltc).
(atu�+a adu::ocal��,ifacce�iry w a,c!v�iasforma�oo pertai�w.rJ ooa7-_.e'.n:z)
{ ) I am a sole proprietor and bave no one working for me.
( ) ming all the work myself
I am.a home owner perfor
i
NOTE:pleat be extrc it,.kt le hcmca�vcrs w'oo aaPIQY P� w d� -• ��r r rc�air +ori o�.d..clL^ of
oat mete th:e ' x—0 in with the bocnoo,n r=ich or ea the p-ou06 197,r L, tbeto�-c o-x _-.1 }y oca:daai w he
cirploycs unl c the..•oi;a'a o=T•==iipa Acr GL152=15
� � )�=WU=6om lry a hotncoava fm:Lic=_-=or permit any e,ideooe tJ:e
ployec under dso Wortoe,Coc p.r tion Act-
I u.od.--d thm a Dopy of thin—1-1 m.y bo foe-a.nrded to tbo popnrtmmi of Induuiel M-`a&.1y Ofsi—oC Gas+nnoe for ihe
oov=2-�veriCeslioa and th1 L-um to sea=tvvernbt under suction 23A of MGL 152 eta ied to the impasitioa of c imiaal pent =
coallri ns of a rax of tap W S 1 500.00 arsdror iaa3priyoacoc=of up to one year rad o�i1 pm+tio w t�form of a Sots Wort Ord=pad.
rtm of S 100.00 a d_y t&Liast Mr-
For d.i.-�T-^"�—only -
.��iG ' C_-•" Permit Numb= _
Lot Y
�� •Lr
sigm-iturt of LiccnscclPcrrT iucc J
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
Reaisterec }domema o�ementonct c' zF Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 1'0-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL.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 assu esponsibility for compliance with the State Building Code,City of
Northampton Ordinances,State and Local on' aws and State of Massachusetts General Laws Annotated.
Homeowner Signature
A
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) E Roofing 11
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[0] Other[a
Xnef Description of Proposed
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa, f ew la�rse.and a add tlor kaexlS#ng..i lsinn;c rte` nth a'T na:
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,--OWNER AUTHORIZATION-TO,BE:°COMPLETED WHEN
OWNERS AGENT OR.CONTRACTOR-APPLIES FOR;BUIL]jING.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
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.
Z�L(J
Pri Name
lw C�
Signature of 6wnKAgent Date
m �
° -
'
Section 4. ZONING 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
Frontage
Setbacks Front
Rear
Building Heigbt
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Vuriance/F ever been issued for/on the site?
NO 0 D0N7 KNOW 0 YES 0
IF YES, date issued:!
IF YES: Was the permit recorded ut the Registry uf Deeds?
'
NO �� DON'T KNOW YES
\_�
IF YES: enter Booh � Page, and/or Donument#'
'
��
B. Does the site contain ubrook, body of water urwetlands? NO �~��� VV ��.DONT �NO YES
IF YES' has a permit been or need to be obtained from the Conservation Commission?
Needs%obeobtained ` k_«Obtained x�� Date v~� ' �
C. Do any signs exist on the pvoporty �� ��� 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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre nrixit part ofo common plan
that will disturb over 1 acre? YES ��K � NO ���)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton 4.
Building Department
212 Main Street
Room 100
Northampton, MA 01060 _
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -VTEIIINFORMATIOR
1.1 Property Address: ,
This section to-be completed fayoffice
L �-
/ / Af, / Ma ti t t1n�t
t
M /1 �Yey /" Zntle QYBIa3tSt[ICt
Flint DtstrrcL CB DIStCtcL
SECTION 2—PROPERTY OWNERSHIPlAUTHORIZED;AGENT
2.1 Owner of Record:
CT
Name(Print) Current Mailing Address: �YS'_ � /
&��s q'
- - Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone_T SECTION:3-ESTIMATED CONSTRUCTION COSTS.
Item �q� / ,[ Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
Building'Permit Fee
1. Building
2. Electrical -�(b), stimated.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 Qjl)
This Section For Official Use Only
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2006-1369
GIs#: � . COMMONWEALTH OF MASSACHUSETTS
at 11 T 4, " CITY OF NORTHAMPTON
Lot:-001
Permit: Buildinq
Category: BUILDING PERMIT
Permit# BP-2006-1369
Project# JS-2006-2021
Est.Cost: $3500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 10367.28 Owner: PALUMBO LISA M&GREGORY ERAMO
Zoning: GB Applicant: PALUMBO LISA M & GREGORY ERAMO
AT: 5 BRATTON CT
Applicant Address: Phone: Insurance:
5 BRATTON CT (41) 358-5949 (1)
FLORENCEMA01062 ISSUED ON:611612006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE
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 6/16/2006 0:00:00 $25.002010
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
5 BRATTON CT BP-2006-1369
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-201 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-1369
Project# JS-2006-2021
Est. Cost: $3500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa.ft.): 10367.28 Owner: PALUMBO LISA M&GREGORY ERAMO
Zoning: GB Applicant: PALUMBO LISA M & GREGORY ERAMO
A V l d C..T
Applicant Address: Phone: Insurance:
5 BRATTON CT (41) 358-5949 (1)
FLORENCEMA01062 ISSUED ON:611612006 0:00:00
TO PERFORM THE FOLLOWING WORK. STALL WOODSTOVE
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: oiC o q/a 8/O 6 LWd I S
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupano --► /v-/ -I_le_Sijz nature:
FeeType• Date Paid: Amount:
Building 61116/2006 0:00:00 $25.002010
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Coirunissioner-Anthony Patillo