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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, 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 his/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 orieTor f o j and y
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."
TheUuil tng department for the-City oTNorthampton wants-any persons)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 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 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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DEPARTMENT OP DUIL )r�\,C INSPPCrrOI.S s
212 Main Strcct Municipal Building
Northampton, ATacs. 01060
«'OFJIIZ'S COiATENSATTO.N 13'iSUIZj�hCE AFMAA777'
(liccnSxJpermittcc) __ --
%VILh a principal place of business/residence at: -
I q
Alm cc-/c- s A CV-W-C-5-n- (�hone') ✓YG � 7��
(s�tici r;/stattfa D)
do hereby certify, under thc.paim and pen2lties of pcgury, Lai
j ( ) I am an employer providing the follo%vine "Yorker's comocnsaoon covem-oe for lm
employccs wor.Ung on this job:
(irsexan= Coarzzzy) (Polio: ?:u--.�-r) --' (•:'piston, Dat--)
I
( ) I am a sole proprietor, general c:ooa acor or homeowner (ci cie one) 2nd h2ve hired
the contractors Listed below rrbo have the `okwinQ workers co policies:
0";amc Oi Co:unczos) (In2ranc c COInDa]}•(i�GUCi (–E�:7)1FJOon D.Itc)
i
(Namc of Coaezaor) Rnsa.rancc Comp_ anw?o!ier Nunc_r) (La-Dimon Date)
(Name of Condo.) (Insuranc; Company/Poucy Nwmbr) (Ecpir=aon Dalc)
i -
(Name of ContMclor) (Cosuranc- Comrzay/Policy Numbs) (Expi z6on Dart).
(.titer.3ii�oicC.if accc._y to mducE to.1I
iaformi�oa.
p wa-san)
I
( ) I am 'a sole proprietor and have no one world.ng for me.
( } I atn,a home owner performing all the work myself.
1 NOT!:pl–..b ecrirc rti }c bem�acr�.vto employ Dc`zoui to cS3 c c=--.=oa c rtes.vm cc a d%,•c --;of
not taocz tea ' sr qtr is y eti the bomoowac raid-,or oa ehc}�v�ac,ZF?Urtca-=tbecn&- ox C---a= y ors d�ni to be
ei>ployca uaG=the��S dz�__,•oo Aa(GUI 52-=I(5)).=.pptin000 by a bomco -ocr fc c lip.or pemiI=zr c,-kI0c the
1eF,sl ct�au or ea esployer uada d–Workdr Coczpemitio AeL
I undca= od t : of tbi.m=omma o be ford.a,'-d to Lb.j O°PY Y ict A mt•I Offio.o( for tb.
Opv--R4 c"aZc=ioa ad the L-iliac to secure'eovcrnbc uodc soeiion 23 A or}.SQL 157 an Icd to the imp=i ioa of eimias!P-16a
comzrrsg of a floc of up to S 1.300.00 end/or of up to ooc yczr sad evil pmilua io d.form or.Stop Work Ora .ad.
j fits of S 100.00 s d_Y LPIC:g me
f For dcp�rta�-�u+c Doty -
j Pcrmrt Nttmtxs
Lot
S'9'aa tac of Lic=ixx/Pcrrn-iucc e J I
SECTION 8-CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
t @4!s" e 1 Sinn emeco o Not Applicable ❑
/4 S-eee
Company Name
/� Registratio -t-n um er -- -^
d 7z/-0�O,0"
Address Explfratio6 Date
Telephone-5�, + �7�`L--
SECTION 10-`WORKERS'COMPENSATION INSURANCE`�AFFIDAVfT(M:G:L-.c.,162,-,-§2$C(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...... ❑
�s
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.
AIso 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•all applicable)
New House ❑ Addition ❑. Replacement Windows Alteration(s) ❑ Roofing
Or Doors I i
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[E3] Other[C7]
Brief Description of Proposed.
Work: �� 5//t LL rr�Jcril� lc//stcxi�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
s" evrw ousen � c!' t� .� xts -ncl oust a .;comple�ta�#h�>�ili�mr�:
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 AUTIH ' ATION6B
,- E COMPLETED:WHEN;
01iYNERS AGENT AR CONTRACTOR APPLIES FOR BUILDfNG:PERMIT
l 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 Own /Authorize
A ereby declare that the statements and information on the foregoing application are true and accurate,to the best of edge
and belief.
Signed under the pains and penalties of perjury. '
Print Name
fs 8�a S
Signat f Owne 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 %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume,&Location)
A. Has a Special Perm it/Variunce/Rndi ever been issued for/on the site?
'
NO 0 DONT KNOW 0 YES 0 �
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES
IF YES: enter Book Page' and/or Documant#
�� ��
B. Does the site contain u brook, body of water orwetlands? NO �_��� DON7KNOVV �_� YES �~�
IF YES, has permit been or need tobe obtained from the Conservation Commission?
-
Needs tobmobtaimad »�� 0�tm�med /~~\ 0m�e|ssue��.
�.� x�� .
C. Do any signs exist on the propert �� ��y? 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 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb grading,excavation,m filling)over 1 acre misdpart ofa common plan
thaw@|disturbovor1ocre? YES NO ��K �
|F YES,then o Northampton Storm Water Management Permit from the DPW is required.
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City of Nort�arnpton
130jl' ing Department
2 Main Street
i.'
z' C5 Room 100
North mpton; MA 01060
pFt s 3-58 -1240 Fax 413-587-1272 ,
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -$11W NFORMATION
P Ths sectron to 3becomQletedby oEfce
1.1 Property Address: r K
Y
6 /�G• /M-
SECTION',2-PROPERTY OWNERSHIP/AUTHORIZED AGENT ..
2.1 Owner of Record:
7A49 WJ /v,0 • M.6 f=7
Name(Print) Current Mailing Address:
i
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
1--
1 ure Telephone
SECTION 3-ESTIMATE&CbNSTRUCTION COSTS:--
Item Estimated Cost(Dollars)to be Official Use Only
com leted 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) / Check Number
This Section For Official Use Only
Building Permit Number Dsued:
Signature:
Building Commissioner/Inspector of Buildings Date
81 NORTH MAIN ST BP-2006-0399
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-246 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2006-0399
Project# JS-2006-0580
Est. Cost: $1789.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq. ft.): 20560.32 Owner: HAIRSTON ANDREA&PAM WELLAND
Zoning.URB Applicant: John Corbett
AT. 81 NORTH MAIN ST
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON.1011212005 0.00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS
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 10/12/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo