31B-023 (4) ¢�t1AM P
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DEPARTMENT OF BUILDING INSPECTIONS /=
INSPECTOR 212 Main Street • Municipal Building '
ay s
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as i:is/her construction sup,,: .- 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 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
�•�lw-r�T
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F �ti Crif-�3 Crf
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v~ DEPARTMEIJT OF BU11Df\10 INSPECT10t S
212 Alain Street IsTunicipal Dwiding
Northampton, Mass. 010GO
\VOR10ER'S CONITENSA`IION •LNSUI CE All=I AVIT
w 6 S ., r �-_- - - ---
v,riLh a pr`Lrtcipalplace ofbusines resideence at:
/
(srst/c� /sZatL/ap)
do hereby certif)--, under Lbe.pzint and penalties of perJufy, hal
(,'�Ii am an employer providing flit following workers comoc)sadon cove—.Sc for my
elupiovecs worlong on this job:
0® ,
nor Conn=v) (Polio: Nu-m6u) -- ( :oirtior, Dar--)
( ) I am a sole proprietor, general conrracor or homeow-Der (ci_cie one) and hzve hired
the contractors listed below c�bo have the folio%vi9g worker's C-O otnsadon policies:
(N-amc Oi Con.m.laor) (Iris r3ncc CaiTipa l)•/PoUCi NlumhCr) Date)
(Name of Coocraaor) allsdi-ante• Comoa.n"•/POUM, Number) (—E»ir Lion Date)
(Name of Coun-ac-16) (nsuranec Company/PoUq• Namb�r) (Expirdoa Dale)
(Na.mc of Coar actor) (Lnsuranc—c Compauy/Policy Numbs) (Expiradoa DaLc) .
(aQar.+r�s�oczr c'ua.ifa�+•- �•to c�ctucL in(orm+�oa pc�"�to.11 comer-..cv�)
r
{ ) I am a sole proprietor and have no one working for me. L
( ) I am,a home owner perfori' g all the work myself.
NOTE:pi=--.t be conic ii--�•f Jo 6emr� von�t,employ pc�to 6� cam-c o cr rgza woric oa c d%,-J:-Z of
aot mote thco tbee=r,'in inch ibc botnno c^ =raids or oa the avuz F zppurteas-tbet;n oo(C-x..ny oci=rd=d to he
-cirploy—u' the jai u:0 1 as Act(G L132=l(5)�=4*Li=L6on by a homco -=far c lice_or pawn zy e deoec the
Icga!n,^•"of=c=ployx uoder d=Works ,c Comp,m L; a A<L
l uadezuad tb-a oopy o(thi,mtemmz o y bo foe-- ded to ub.pepnnmm of OM-of[r� •000 foe thu
oov-->&,c veTIc=IIw n_•td t}--I L-Ijure to striae'Cove under roe oa 23 A of MGL 152 can I=d to the i--P 3 0a of tin i pe�-
com_siab of a fioc of up to S I-�Oo.00 utd/oc mmprisoamDczd of up to ooc yc:r c.od 6Nil pauP.ic io 6c form or,Stop Work Ord--and
frm 0(5100.00 c d_y catiaA t>x
- For dcy.rtm=�)u.c only .
- --�.'� 6 �. 0 Pcrmrt N rr�t>� -
1`�1p.' Lot,'
Sipa.ttun of Li�saJPcc�niu
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SECTION-8—CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: (�1 Not Applicable ❑
Name of License Holder: �
License Number
Address o 6 6 Expiration Date
Signature V Telephone
9 Regstereifytiorrie3`linpioveierit Not Applicable ❑
&)d / !V fit'
Company Name Registration Numb
Add r r/ Expiration Date
"V�' Telephone Q 0 7,b 0
SECTION 10-WORKERS'COMPENSATION INSURANCE,AFFIDAVIT'(M.G.L c.152,;§25C(q})
Workers Compensation Insurance affidV-vg must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the buil per mit.
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:Per-son-(s-)-who-own-a-parcel-ofland 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 5 DESCRIPTION OF PROPOSED WORK(check all applicable)
New House Addition Replacement W' dows Alteration(s) F-� Roofing F
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[C]]
Brief Description of Proposed
Work:
Alteration of existing bedroom Ye No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a`lK:Neviihousandor,�r�tion�fo exlstrn housrngcoriiptethe,�otfot�rang:
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 z OWNER AUTHORIZATION,=TO=BECOMPL'ETED -1AFHEN
OWNERS.AGENTOR'CONTRAGTOR'APPLIES FOR.,BUILDING.P.ERMIT,
,� ti
�/ as Owner of the subject
I, t�a r9 � c 5!
property >U n� l ' j
hereby authorize !
to act on my behalf, in all matters relative to authorized by is buildIng permit application
gnature of Owner Date
YL) as Gwt+*MAuthorized
Agent hereby declare that the statements and information on the for going application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
A ro l�
Print O r,R^
signature of sAgent Date
4f ~=
Section 4. ZONING All Information 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
(volume&Location)
, *
-
A. Has a Special Perm it/Variance/Fi nding ever been issued[or/nn the site? .
NO 0 DDN7KNOVV 0 YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO � ) YES��
IF YES: ' enter Book Pag and/or Document#:
B. Does the gtecontain a brook, body ofwm�rorwet|on�? NO DO07 KNOV � vLs 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained Issued:
Obtained �~� Date
v~~/ �_/ ' '
C. Do any signs exist on the property �� ��� 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 0 NO v0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, gradingexcavation,nr filling)over 1 acre orisi1 part ofa common plan
that will disturb over 1 acre? YES ��[ � NO ����
IF YES,then a Northampton Storm Water Management Permit from the DPW is required-
� � De�artmentwuse only �:.
P
-City of Northampton
Statusfetaatt
Building Department each
212 Main Street SeiESep
Room 100
+gate� vaita6tf ���1
F l a» ct �ns � ti
_i)U0 Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272Isti
APPLICATION TO CQNSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION A-SITE INFORMATION
/
This secti my ofce d
1.1 Property Address:
3TTT tJnit
Zo f
y� xie. Overlay 1]istract_. �
Elrfli'S�'DISt�'ICt� _. CB��strlct
SECTION 2-PROPERTY`OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�`o u Pi
Name{P' Currerj/A ili g+Vdress:
✓ _W_._ Telephone // ,
Sig 4�-- �J
2.2 k thorized Agent:
Name Print) Current Mailing Address:
` X116''7
ignature Telephone
SECTION 3=ESTIMATED°CONSTRUCTION"COSTS
Item Estimated Cost(Dollars)to be Official Use Only
,completed by ermit a ficant
1. Building -ry ��: -(a)?Building Permft Fee
2. Electrical »w_ (b}-Est!mated�TbtalCost of
Construction.'from,6
3. Plumbing Building Permit'Fee
4. Mechanical(HVAC)
5. Fire Protection 4
6. Total=(1 +2+3+4+5) Check Number
This Section ForOfficia(Use Onl
Building Permit Number, te
r.
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
19 ALDRICH ST BP-2007-0470
GIs#: COMMONWEALTH OF MASSACHUSETTS
MW.Block: 31B-023 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-2007-0470
Project# JS-2007-000692
Est.Cost: $3835.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: B & R Siding 100465
Lot Size(sq. ft.): 3136.32 Owner: SHEA MICHAEL H JR&JOANNE SHEA
Zoning:URC Applicant: B & R Siding
AT. 19 ALDRICH ST
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTONMA01060 ISSUED ON.1012512006 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 10/25/2006 0:00:00 $25.0020616
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo