17C-246 (4) 4THAMp�,
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�I111A34AC}t3lSttt4 -
DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR 2,12 Main Street • Municipal Building S",F
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 1:1s/her construction sup,::., sor. T he state defines "Homeowner" as, "-Person(s)
who owns a parcel on which he/she resides or intends to be,a one or two fami�_
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 fegulations. 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 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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DEPARTMENT OP DUIIDr),ZC INSPEC71ONS
212 Main Strcct ' Municipal Building
Northampton, Mass. O1O60
W O RICL R'S CO VIII'EN S A'nO N G S URA CE A IT'D)A.tTI-l~
_71� _77
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l7i cxvsJpermlticc)
«rith a principal place of businessfresidence at: -- — --
— (phone:')
(sts>wt/ci t}/sutdzi p)
do hereby cerdi -, under thc.p?ins and pen2lties of per3ury., -Ih2i
( an employer providing the following''wor-kcr's coinocnsa�jon cove—IS c for in)
emplovecs wor1,2119 on ties job:
i
(Iast1_r-az=Conr,:LIV) (Potic:Numir_r) -- (t :-pirz on Dzl:)
O I am a sole proprieror, general contractor or homeowner (cii Cie one) zod have hired
the cone aciors listed below vgbo hzve- the followinQ worker's comp°rLsaiion pokies:
(INamc Of Contmaor) (Insurance.Cotnoan)•/`PoUCi N1umh-_1 tt_C711du0-,bate)
- (Name of coca-aaor) (bis-waacc Comoaa)vPo!ic,i Num6cr) (LiDir,:tion Date)
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(Name of Couzaclo:) use; Compa.2y/PaUcy N:rmbcr) (Expiraoo Date)
(Name of Contractor) (Insuranc-c Comoauy/PoLcy Numb-:r) (Expiration Date) .
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x�cC,ifnccci�-to cKVC�iafornaoa pertaiai.ns to.t1 oo(r_-_=.o:a)
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{� ama sole proprietor and -have no one worldng for me.
( ) I am,a home owner performing all the work myself.
NOTE:plcx lx zwzrc,,,.kF Ia bamr� vcrs k!�q�1oy roc r to .r^r• cs c ao c tc-aa wort oa a of
not taoco th_o t'-sa-_vans ish$ Ux bomoo—w r=do or ca the p ouac,,,�purtcar_tbeeo�z nx��rity ocrs d 10 be
eirployc�uric the..ui�: uea Act(GL152_s 1(5)�=ppCu=.6oa by a bomco .,=fc_lies__cc txsmit r=y c idco«eLe
legs!rt a or r'ez2loyar under d.Workals Co¢xgoos..tioa AL
t„ad d d> d,c-yy of thi. tt m my be fo< carded ro U_Dequrm�os of z�;tj Aocd=&Ow-of i=u+ooe ra LE-
c°vc+'Ec"aif atioa°td ttu f i7r�do scant'Co`csasc u3dcr soctioa 25 A of MGL 151 an Icd to tbo i=;=iioa of mmiusl pcc-%Wcs
coomaims of L rmc orup to s 1300.00 nd/or j=pisoao,=or up to one yrzf L".1d aril pmsYio is tx form of a Stop Work Ord-Lod L
Corr of S 100.00 L d_y LpiaA me
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For L-_Y�7
map." Lot.'
S tun.of LianscslPcnniucc �-fie -- i �:
SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9 Re4 sle'recb tom In irmenve i Not Applicable ❑
Company Name Registration um er ----
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCEi4FE1DAVIT(M-G.L.- 152,s46d(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...... ❑
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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
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SECTION 5-DESCRIPTION OF PROPOSED WORK{check all-applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding [0] Other[[3]
c
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes/,-
e No Adding new room Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
fig, ;srr 'r,.. %`^.izx:, ". -?=*'°; ,.. ""'•,t .= t'S+' .�^:�'.
sa I Nev�w Ouse :I� d lam.�extslE>�ncl�o�islncr..co�is�e
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
L 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"ORGONT.RA'ETOf7APPLIES FOR BUIEDING�TERMIT-
I as Owner of the subject
property '`
hereby au4orize a G�
to act on my behalf, in all atteryelative to work horized by this building permit application.
Sig ture of Owner Date
l as Owner/Authorized
Agent herebi 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 e
Si ture of Owner/Agent Date
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Section 4. ZONING All Informatio'h 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
_—������� ����� '
A. Has a| Perm it/Vurionoa/Findi ever been �suedfor/on the sha?
' �~� x'~� x�� �
0Q �� D�7K�� �� �� ��
IF YES, date issuo&
IF YES: Was the permit recorded at the Registry of Deeds?
NO K J 0ON7KNOW 0 YES
IF YES: enter Book Pug and/or Document#'! /
�� ��
B. Does the site contain a brook, body of water orwetlands? NO ����� DON7KNOVV x�� YES v_�
IF YES, has permit been nr need mo be obtained from the Conservation Commission?
`
Needs tobeobtoiomd x~~� Obt�i�ad v°�` Qm�e |ssue�.
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C. Do any signs exist on the pruperty �� ��� YES �~� NO v_�
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES x�� NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre orisit part ofa common plan
that will disturb over 1acre? YES K } � NO � ]
_ ' _
IF YES,then o Northampton Storm Water Management Permit from the DPW is required.
of Nortf ampton I ��, 11 U7 t°
-Building Department
212,Main Street e
�opm 1,00 MAY .
Northampfpn;'MA 01060 ets�t a t
phone 4131-5,87-12 0 Fax 413-587-1
APPLA!I;1 N TO CONSTRUCT,ALTER,REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION"1 -SITE INFORMATION'
1.1 Property Address:
This section to be'completed by affcce
NtaP Lot Uctit
Zone w Overla}rDistrFct
EIriSt Distrrct CB Distncf
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEID AGENT",
2.1 Owner of Record:
Nam rint) Current Mailing Address:
Telephone _
Sign uref �}
2.2 Authorized Aoent: ,
Na ( rint) / Current Uailing Address:
Si6aatdre Telephone %
SECTION 3-ESTIMATED-CONSTRUCTION COSTS.
Item Estimated Cost(Dollars)to be Official Use Only
m leted b permit applicant 1. Building �/� (aj Building;Permit Fee
2. Electrical (bj Estimated Total Cost of
Construction from 6"
3. Plumbing Building Permit Fee.
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number
This Section For-Official Use Only
Date
Building Permit Number` ssued:
Signature: r
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Building Commissioner/Inspector of Buildings Date
81 NORTH MAIN ST BP-2005-1106
GIS#: COMMONWEALTH OF MASSACHUSETTS
Mag:Block: 17C-246 CITY OF NORTHAMPTON
Lot: -001
Permit: BUiWing
Category: BUILDING PERMIT
Permit# BP-2005-1106
Project# JS-2005-1501
Est.Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: James Roberts 117154
Lot Size(sq. ft.): 20560.32 Owner: EMERY JAMES
Zoning:URB Applicant. James Roberts
AT. 81 NORTH MAIN ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMFTONMA01027 ISSUED ON:5110105 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 5/10/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo