24C-155 (2) ��HAMp�o y
(ritJ of 'Nortl1alliptvn
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6 A ass a chits etts
5T r� DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR 212 Main Street to 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 !Js/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 hvo 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 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
gB f31r<saRChusrlta '
m DEPART2,fENT OP BUILDING INSPECTIONS
212 Maui Street ' Municipal Building
NI-orthampton, Mass. 01060
WORrCEM'S COMPENSATION TNSURA.NC'E AFFMAM
(IiccnscrJpermittee)
with a principal place of busMessJresidence at:
(sti cc-Ucitylsta.tc�7�p)
do hereby certify, undler the pains and penalties of perjury, that.
( ) I am an employer providing the following: workers compensation coverage for im
)loyees working on fliis job.
c� Company) (PeLc, NLLZiber) (F�pirtion Date)
( ) I ana a sole proprietor, general contractor or homeowner (circle one) and have hired
the contractors listed below vf]o have the follo,VLFlg workers cornpensa4ion policies:
(Name of Contractor) (Insurance (--om^2nyTo!1cf Nurnbcr) (Expiration Date)
(Name of Contactor) —� — (Ensur,n.e Co nit-,anv/P(D!1c)' Number) (E=xpiration Date)
(Name of Contractor) (Iaairanc: Com•,a❑ IRoG Number) (:ixpiratioa Date)
(Name of Contractor) jasunuic- Comrrrny/Pohcy Numb-r) (Emir lion Date)
(etLadl additional si�.Yt irnecenir::n
i
O I am it sole proprietor znd have no one rderku]tj for -me.
O I am a home oVme]- pclonnin all fi]e wot. iii`rs 1f.
No'rE:plcaac be a�ruc that tti?-ilc Fx<n v.1r s.ti;�r.:,ploy trz :s n rrpair ot>;cn
not ax-ce than throo wilt,i1\%i-jdl d ka,Lvov?rr3iL�71 of oa Lu t •_r:s: ,.uttcr�nl L acio c c n x 6crxr2lly crc-J id-:r':3 h
—Iploycr3 under tlx�wri r>s cxxnpctatim A (GLI S�<•1(Sl),apph_anc,by a horuo«n r for a 6ccwc or per:Li:
]cgzl rtatuc of an amp loyor uoder tho wo<1cc1.cotnjxcnation A,&-
I undcraAnd thtt a copy of Oh rtnt=z rA nLy bo forw-z,,1od to tbo D;part.�of lod u:riel Ac66 ,&Offl w of li::u" for tlzo
coverage vmficaiioc and th t failure to!4,Dzt covcrav urd_.r sccuoa 25A of Liar.152 can load to tho=pcsition of critnii' pcnak:cs
consisting of a fix of up to S1,500.00 of up to on:}-Zr A.-A eivi]politics in d�farm of a Step Work Once-*-rd a
finc o(S 100,0 a dsy igAimt nr_.
For cicS%utnrsdal u—only
Pcrrnit Nttmbcr
5l�naturc of
.c.h-;ikfiu.-.:., ,
SECTION B CIjaNS7RUC74 N SERVICES
8.1 Licensed Constructions Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
ee stere° time mp.buementC n "f'C:! = Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORK.ERS',CO,MPENSATION 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...... ❑
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
SECTION D 5 y RTilO .OFPROPOSED Of2k� c,1 -,4 Il,ka 'Ylicabl'e `'
� r �'
�
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: a" �l
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative ❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ - Sheet❑
a If Ne ho se and o A diflon" -OTUY ing housin Raffl 11e a thefolI i-�:
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. Mascheck 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
SECThON7a OWN ER�AUTHORIZATION TO BE COMPLETED' WHEN
OWNEaSAGENT OR CO'�NTRACTQR APPLIES'FOR;BUILDING PERMIT
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 &wse+-/Authorized Agent
hereby declare tha 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.
C ��
Prin e
Signature of Owne ent 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
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Findin ever been issued for/on the site?
NO 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 _ and/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
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:
of Northampton ratus o`
_.._._--�, i ing Department Curb C�ft 1:�
i' 2 Main Street Sew rSe t
2N3 Room 100 Wa erl� t_
JUL 3 0
N rtha pton, MA 01060
587 1240 Fax 413-587-1272 1?Iot
ptv;OF gttlCl!tG Ip�0 460 -
LICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section;to,be completed by office
1.1 Property Address: ,_ 11 Map L`ot£ 11n1t
Y1� e.-T\ k
\ , Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY-OWNERSHIP/AUTHORIZED AGENT —� --- —
2.1 Owner of Record:
Name(f?rint) Cu rent Mail ng Address:
leiephone
Signature -- -- ---
2.2 Authorized A ent:
Na Tint) �,rrent Mailing Address:
Signature lephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant_
1 Buildin (a) Building Permit Fee
%- Ele irical (b) Aimated Total Cost of
Construction from 6
1 Plumbing Building Permit Fee
4- Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) kni, °'— Check Number
This Section For Official Use Only
Building Permit Number: - Date Issued:
Signature: ------ —
Building Commissioner/Inspector of Buildings Date
--
BP-2004-0088
G1S#: COMMONWEALTH OF MASSACHUSETTS
- CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:- BUILDING PERMIT
Permit# BP-2004-0088
Project# JS-2004-0139
Est.Cost: $8000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: CDT CONSTRUCTION 130152
Lot Size(sq,ft.): 20168.28 Owner: KEPPLER ANNE F
Zoning:URB Applicant: CDT CONSTRUCTION
AT. 50 ARLINGTON ST
Applicant Address: Phone: Insurance:
158 NORTH MAPLE ST (413) 585-8677 Workers
Compensation
FLORENCEMA01062 ISSUED ON.7130103 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 Occupangl Sienature•
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 7/30/03 0:00:00 5358 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo