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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building '" 5 •';
Northampton,MA 01060
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:-,,;s 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 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 hour), 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/ sident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date ?S `7 c
Address of work 7—
location 8 ,�'`�hfk, /,-(A(, ` ` ('�c e,e c
Y
r 6 fit LS a A C II it r,C t tS �✓
m DEPlu2T1 �r iLA OP LUILDING INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WOMCER'S COMPENSATION INSURANCE A t MA IT
v,,Ilh a principal place of businesslres,dence al:
CIO hcrcby Ccr-di�'. L:];ICI ?I1C 1J iil$ ;i]7 pCil 1Ll' .: of Cr�llf�, tha"
( ) I am an employer providing the ollo',vir]t, v"orr_cr`s Compensauon cover' c For my
employees working on t ils job:
(Insurance: Comprm') ci ic,N=Ler) --- (F Trinaon Date)
j I awl a sole proorictor, general (cLrCle one) and 't:a',te 'tired
t-he contractors listed below;;ho 1l- the
_ v Ofit COu lJ 114uQrl .,�.:,,.c_.
(Name Of C-OrILMCtor) ( nSL_..IlCC Cvt ^?"ie': GIV j N=nb--I)
(Name of C=T-actor) Date)
(Name of Contactor :37
) (Insr tics Co; -10 /'Policy Nuirtf�r) ~.x. r do Latc)
- (Name of Contrlctcr) — (Ins atice Comm :}.Polio Numb-1) fF xni ::io Dale)
(CILtGl•'-dii�lCCl1l SP:_Ct ._'-_. .-,..r...,-....�Y:..i_..,. , ._.... � ...i.-.._.-.....,.-i
1 aiIl a .OIC 1:rO1?Il CJi i'.:1Q hiavC, 110 Ol]C Orhi]'' 1o1 it?e.
NOTE:p(csa Lac a:rarc tl: ]c kx xo ;r-s .rc-� -pl:^ ; n:. ::.__: ncc ar::_n~m cr::;:a l 11,11K i�•ctii g'•
not unite th_a tlu-eo units in«t iclt rc:,;Zz u e;t -�._;.s=^t'_r e:�r1 Lhcrc z:-nc<Cerxrall V a :::;.:c :c lti
c^tplcycz ua'.cr the:vcrLx:a cc xc>:i:r. ;r:(GL152.--:!(5)1.r,r •==:ic:;by n homco«•ncr:`or a
ltgal ctatuc of an a=plo}'e under tl_n Wo i c1c t 2-txr motion .cL K
I undczta d thL a copy of that ctsta:- 'cuy of i::;+.0 =n for the
covcrasc vaiE=Iioa and thst f:ilurc to to c co'.:-rzM ut^-r cciM 25A of MOL.152 can 1,-,i to the inrf asitian of cr i_1 pct:sl::s
Cvumiatmg of a fur-of up to S 1-500.00 an:'.'Cr of::p to cr,:}- a:.I civil—,-Mltica in tc lclorl c.f r S:c-- `;Jc i'.C}1i arA a
fits ofS1Q0.00 a day i��.in;t mc. .
rcx cS`i%uti:rtal u.o cftly I
1�CIInit N ----°--------
�r
SECT-ION 8 .CONSTRUCTION SERVICES!
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Regs"of re' orn ma ouemen"t ontracto Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
ZE CT,,ION 10 WORKERS' COMPENSATION INSURANCE AFFIDAVIT(K;,G.1-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 buildine 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 an assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, St and Loc ws an tate of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION S=D S IR ON OF PROPOSED WORK lcheck It aoalica le)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
/ Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ } Decks [ ] Siding[ ) Other [ ]
Brief Description of Proposed Work: o(d Jet&cked -cam 4 6 oL
Alteration of existing bedroom Yes /No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
_sa F>fi N'ew souse�' ` istin?hou s in m1e �ehe fo(hwdlo� tlitrr ez in:
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
SECT�t3N7a0WNERAUTHORIZ4TION TO I3E COMPLETED WHEN
OWNEFtS'AGEN;T, i COi!lTRACTOR'APPLIES"FOR BUILDING PERMIT
I, as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this wilding permit application.
Signature of Owner Date
I, 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.
Q
Print Name
ignature of Owner/Agent 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 0 J k
Fronta e � 1
Setbacks Front 5f
Side L: � �R: L: R:
Rear
Cfv
Building Height s
Bldg.Square Footage 14focg %
Open Space Footage ` %
(Lot area minus bldg&paved C9 Qtr. °
parking) / �1 S
11 6
#of Parking Spaces o�
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ol� DONT 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. VAre ere any proposed changes to or additions of signs intended for the property?YES
No
IF YES, describe size, type and location:
r
City of Northampton
Building Department
212 Main Street
k
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-12
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOV DEMOLISH A ONE R FAMILY DWELLING
E i AUG 2 4 2004
SECTION'1-SITE INFORMATION OFD �r RI"lh'"`;LOA ningnFS
pleted by office
1.1 ProoeM Addre55:
Fl rte -, /t�(/� (� cT- Zane k ' vertay D,stracl4 x
3 �✓F `� J j 'A' � Y
'�^EIIn�i .�DIS`tr{Ct _s- yr � w f 4 s} ,'C$DISti7Ct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZEa_AGENT "
2.1 Owner of Record:
,5tew..,it
Y
Name(Print)--'�' Current Mailing Address:
Telephone q-1;1596
Sig ature
2.2 Authorized Agent:
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
L Building � (a) Building Perniit.Fee
2. Electrical (b)Estimated-Total Cost of
Constwction from"6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
S. Fire Protection _
6. Total = (1 +2 +3 +4 + 5) Check'Number
,GG This Section For Official Use Onl
Building Permit Number: V 64w Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0221
APPLICANT/CONTACT PERSON STEWART ROBERT B&
ADDRESS/PHONE 58 NORTH MAIN ST FLORENCE ���✓aa��
PROPERTY LOCATION 58 NORTH MAIN ST
MAP 17C PARCEL 258 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Ty_peof Construction: CONSTRUCT 20 X 22 DET GARAGE
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 F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION 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 Co sion
8 L00 .
Signature of Building ficial 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.
58 NORTH MAIN ST BP-2005-0221
GIS#: COMMONWEALTH OF MASSACHUSETTS
It p Bloch: 17C-258 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0221
Project# IS-2005-0273
Est. Cost: $16000.00
Fee: $66.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 23870.88 Owner: STEWART ROBERT B&
Zoning:URB Applicant: STEWART ROBERT B &
AT: 58 NORTH MAIN ST
Applicant Address: Phone: Insurance:
58 NORTH MAIN ST O 586-2252 (�
FLORENCEMA01062 ISSUED ON:8130104 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 20 X 22 DET GARAGE
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 Sienature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 8/30/04 0:00:00 663 $66.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
BP-2005-0221
58 NORTH MAIN ST
COMMONWEALTH OF MASSACHUSETTS
GIs O
CITY OF NORTHAMPTON
Map:Block: 17C-258
Lot: lo PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
BUILDING PERMIT
Category:
Permit#BP-2005-0221
Project# IS-2005-0273
Est.Cost: $16000.00
Fee:Cost' $ PERMISSION IS HEREBY GRANTED TO:
Contractor: License:
Const.Class:
Homeowner as Contractor
Use Group:
Lot Size(sg ft.): 23870.88 Owner: STEWART ROBERT B&
I�ofnDCRT R 81
Zoning: LAW
AT: 58 NORTH MAIN ST
Phone: Insurance:
Applicant Address: () 586-2252
58 NORTH MAIN ST
FLORENCEMA01062 ISSUED ON.8130104 0:00:00
TO PERFORM THE FOLLOWING WORK.CONSTRUCT 20 X 22 DET GARAGE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring L.''.W- Building Inspector
Underground: Service: Meter:
Footings: 7 Q.O
Rough: Rough: Hou:;e# Foundat:on:�k 9' J
g Driveway Final:
Final: Final: Rough Frame: V K /0 '9'G v��
Gas:
Fire Department Fireplace/Chimney:
Insulation:
rnQh Oil:
f Smoke: +! Final: d Y 11`G. 0,V
Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION'F
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occu anC si nature:
Amount:
Feel e:
Re t cei No: Date Paid: Check No:
Building
8/30!04 0:00:00 663 $66.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Conunissioner-Anthony Patillo