17C-254 (2) 4�tSMfP�.
� Massachusetts
C1,ify of Worthampton
DEPARTMENT OF BUILDITIG 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 1-11s/her construction sups: .•: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 famity_ _
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 iegulations. 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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DEPARTMEbT OP BUILDr?\,C INSPECT1011S —
212 Alain Strcct Municipal Duidding
Northampton, Mass. 01060
WORTC;I IS CO'INIEP ✓iiiSA`ITON MSURAIrCE AFFD��i��I�'
ni��p��-rr„tta)
%vit_h a principal place of businessfresidence at: ---
(!;hone:') `j Of-
(sa ty/ a t r/a P)
do hereby cerd. -, under dic.pains and penalties of pegury, -hat
( ) I
an an employer providing the followinL',vorkcr's coiPocnsctJor, cove.--g.c for im
emplovices wor-long on tills job:
(.nsusan=Comraml) (Polio: Nu-mbcr) -- :pirrioR Dale)
( ) I am a sole proprietor, general coon-actor or homeow-cer (c cie one) and have hired
the cone actors listed below wbo have the following worker's coc27ep_saIIon policies:
( +1IDC of CO„^Ci0') (IRRr3t1C COIT10arI}'ihGUCi N't1II1tC ) (-I-v7 nwuoR D'Itc)
(N—c of Contraor) (lasurzncc Compazyi?oucy `urncsr) (l:i-oir,:6on Date)
(Name of Conlsaclo,) (Iusvranc Comp2.c)-/Poug- Numb l) (Expirdoo Datc)
(Name of Contracior) (Lesurana� Compaay/Policy Nunabzf) (E%pir600 Date).
(a[Ia.Ch ,,:ocsl dxa,ifncocza�-w a�'uc--�=for=-LMoa P�=tciaias to
( I am a sole pro rietor and have no one worl;3n for e
P g o m .
( ) I am.a home owner performing all Lbe work` myself.
NO TIE:plese be norirc t1- kf ]a 6eme�,ve a.�bo es�lay pc-zoos�o w C=—• oa r rgau waric oo.d,,,U--a of
act tvo i tea ` _t^.t t is teb�tlx «oa the U"ncS:pputteo r_tbeeo z c not�e-.11y o-a d.-ai w he
citploycs unC-the---k.,—z _., A= GL'1 S2.n 1
t (5))�:-,^pliaDOa trY a 1)omtAw=fc a tics__or pcmit tty�idm�Lf;c
leg!ct�ac of m cPloyx uoda ciao Wo�k,,e,CompcmaLiov Act
I uodcnaad d"d a copy of tbl-mt—my bo f---,id d to tho Dcqutmr t of Indvzsi 1 Acodc��OQioe of l�w+oo+fot tb.
coverasc velf elioa aad lltet L-.iliac t.o seairc tov�tys�undo souioa 2S A of T.(OL 1 S-1 ca icd to the ia90si iw of cimim l Pca lIic
cocuZz=g of a fine orup to 51300,00 andf” orup 1.o occ Y==d civu Pmaltic in tx roan of a Stop Work Ord=and a
F=or s 100.00 a d:y LPIMI ED'-
For doo=r aa>>1 uac on7Y
PCT='t Numbcr
st cure of Licc scc/Pcrauuec l`�p"__ LO,
SECTION 8-CONSTRUCTION SERVICES +
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:—�l X,,n 6
License Number
ae1�3
Address Expiration Date
j
Signature Telephone -
_ 1 i Ll 742�-
Not Applicable ❑
9�Re isfer"�tfiorne`lm'Eovemei�:.Cont�actor•�°
Company Name Registration Num er ----—
Address Expiration Date
j �1 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...... of
1L ,s�om } xiFemu c
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 and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
r
t '
SECTIQN 5--DESCRIPTION-OF PROPOSED WORK(check all avolicable)
New House [] Addition ❑: Replacement Windows Alteration(s) Q Roofing
�--� Or Doors D
Accessory Bldg. ❑ Demolition Lei New Signs [0] Decks [p Siding[O] Other[0;
Ch+Are
Brief DespVton of Proposed — I
e �
Work: .k'r /�—1 c) AC
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa (f-New.house and ar dd�iial tc ex�stinc hor sina;.:w omp We, ot(aw1
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, oLe N Ta A as Hof the subject
pr e-rty
he by aut orize
t act on y be in ail matters rel tive o work autHrrized by this building permit application.
.9 �E P
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.
Print Name
Signature of Owner/Agent Date
_
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Section 4. ZONING All 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 % 7—,
Open Space Footage %
(Lot area minus bldg
&paved
#of Parking Spaces
� '
A. Has uSpecial Perm{t/Vuhunoe/Findi ever been issued for/on the site?
'
NU 0 DON'T KNOW (D YES 0 �
IF YES, date issue&
IF YES: Was the permit recorded at the Registry of Deeds?
��
NO �� uum / m"o." .^"
IF YES: enter Book Page, and/or Document#;
�� �� ��
D. Does the site contain u brook, body of water orvvet|onds? NO v�� DON'T KNOW v�� YES �~�
IF YES, has permit been or need to be obtained from the Conservation Commission?
'
Needs tobeobtaioed x�� Obtm�oag �-\ Date
�~� �~� ' �
C. Do any signs exist on the proporty ��� YES v_� NO
|F YES, describe size, type and location:
---------
D. Are there an y proposed changes to or additions of signs intended for the property? YES x~~\ NO
IF YES, describe size, type and location:
E Will the construction activity disturb(clearing,grading ation.or filling)over 1 acre oriait part ofo common plan
that will disturb over 1 acre? YES K ) NO K^'1
~~� r .~^
/
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
-
ity rthampton of l?e : -a
r--1 C6 0 rL V 1J� Qepartment Gctteray
21 in Street see e'trc '�
F�'_J �n 100 ester felCAvarEa��
rtharipto MA 01060 uuo Sets o£sfrucfuraC Pfans ��
i'J `- phone 413-587--124 Fax 413-587-1272 iatt5►s ?la s ` � � � 3
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APPLICA �a7 *�,,
t UCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section xo be compfefed by office
1.1 Property Address:
�Flap i�ot rUnft
IV
Mall
ZoAe �Overla�`D�strrct
Q
:'Elm St:District ? �CB Drstrict
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1: wner of Record: �"—�-
f tslt V,1 Vlawscr
me(Print) �� Current Mailing +dress:
v Telephone /i
Signature A
2.2 Authorized A ent:
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
6. Total=(1 +2+3+4+5) e0 Q -I-- Check Number
This Section'For-Official'Use Only
Date
Building;Permit Number. issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0341
APPLICANT/CONTACT PERSON THOMAS ST MARTIN
ADDRESS/PHONE 211 N ELM ST NORTHAMPTON 05—.Pf 7Y 7 S
PROPERTY LOCATION 21 NORTH MAIN ST
MAP 17C PARCEL 254 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out Z'Pi S 2 4! t5
Fee Paid S'
Typeof Construction: REBUILD 3 CHIMNEYS
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
Signature of Building Official 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.