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t DEPARTMENT OF BUILDD\1G INSPECTIONS
INSPECTOR 212 Main Street • 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 his/her construction sup<� ••.,isor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be,a one"or two—fame 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."
The boil ing department fof the City of Northampton wants-any person(s)-who-seek-tv
use the home owner exemption, to act as their o'%6 construction supervisor, to be aware
that by doing so you become responsible for compliance with state building codes
and regulation. 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 your) 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
understand the above.
(Home caner/resid n 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 X14w
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f Poril}Ui)luf_oil _
aZ.Ycchncrtla- _
DEPARTMEI-FT OP BUILDD\IG INSPPCTIOI.'S
212 Alain Street Afunieipnl Bailding
Northampton, Alas- 01060
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WOR=-Rls CoN PENSATIO.N MSURA-I CE ?.FI ?I VIT
\=.nth a principal place of business/residence at: - -
(prone')
I (sti-�.IJcirJlsZal.clap)
do hereby certif}, under the p?_ins and penzlties of penury'., :hat
( ) I am ao employer providing the follo%ving�wQr,kcr's colnacns-:JoP covcmgc for Illy
Ieivplovecs wor nng on ells lob;
(In�us-mac Corer �) (Pclic: N.U=IL-T)
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( ) I am a sole proprieror, geaeral contractor or homeowner (ci:cie one) aid Lave hired
the coouactprs listed below who hzve the 5,611o,-,Iimg worker's coLoen_t2don policies
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(Namc of Co-itmci0r) (Inwrant.c Cornoanyll"GUCi N'U.II1=r;) D.Itc)
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I (Name,of ConiJ~aor) (lnssrz CZ ComDanviPo!iM' (iiptm6on Dare)
(Name of CO=M67) (Iasuranc-- Compa.n}-IPolJi } N;tsb r) (Expi z6on Dam)
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(N2-MC of Contractor) CLaaIranc-- Compzny/Policy Numb:r) k—Etpirtion D- .
(a¢�r�a _d.?i�ccsl bccS.ilnccc.+_-ti•to c�cu�iafonn,�oa pctasa:,ns to.11 o�_.cr:�)
( ) I am a sole"proprietor and "have no one worki.Dg for me.
I am..a home owner performing all the work myself.
NOTE:piece be aMrt t4,. }e hoMCowxn I-bo C ICrf pc..ona to d.O r. c—e,00 c n a .ore on a d••<rt:^ of
rent most then t'.- -=rj in lose'the bo-moowv�rorid.=or oe the a•ouards zppu.�thee,a_-r ox C—_..r..11y oec:d.--ei w be
1 esaployca tanG=the�vai da er.P --,_oo qa(GL152ss 1(5)}.=.ppU=.6ca by n bomcno-oa fw_4i -cc txrma c_y a ideoer the
ic-g1 ct�u of en c.,toyor under aio w«-t•.orr C.om�om,.tioa,loL
I uodeK.ad tha a ovpy Of tbi+-=-aemmx o Y bo for a ard.d to tba Dcpenmma Of IO&a d C fM—or 1--a rot th.
oova-use vCrMc=ioa and tlLt Eiltac to socxarr Lrovcru Se tmdC-=oa 25 A of MG 152 da Icd to the i=*osiaioa of ei' in.l pcc.tWa
woZIr of t rant or up to S 1 X00.00.nNor or up to ooc y=r end c%il pm.rja in t5c form of.Stop Work Ordc--A
j fast of S 100-o0 a day tgiu9 ttx
. For
PCrMjt Numb-
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—Si of Lit�_scr,JPcrmauc: e -- -�
SECTION 8-`CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
�
9tegrsi'er''ec� om' mcir v meiCartfraco Not Applicable ❑
Company Name Registration tNum er - -—
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE:AFFIDAVIT(O,G.L.c.152,§.25C(S)).
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 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.
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 ED
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [p Siding[0] Other
Brief Description of Proposed ' ,/ j(/►
Work:
Alteration of existing bedroom Yes ----No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sat e� v afio use i - `'`r iitl><#w fo a clsfifraWGI G( et to;L—'O i :
a. a of building:One Family Two Family Other
b. Numbe f rooms in each family unit: Number of Bathrooms
c. Is there a g�foota ?
d. Proposed Sof new constructi on. Dimensions
'o
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 nk City Sewer Private well City water Supply
SECTION 7a%-OWNER^AUTHORIZATION-TO'BE COMPLETED WHEN
OWNERS AGENT'OR CONTRACTOR'APPUE, FAR 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
i 'N 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.
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Plat Name,
"I ' 11kAA/A C-1-14 KZ-6-00-
Signa re Owner/ gent Date
Section 4. ZONING All Informatioh 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 ((nn/11
Frontage — � �J`/
C'
Setbacks Front
Side R~ L:? R:-��
— 1
r--f
Rear
Building Height !
Bldg.Square Footage/
Open Space Fo ge r %
(Lot area min dg&paved
parking)
#o ar
ng Spaces
Fill: i
volume,&Location I'
A. Has S cial Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW"__ YES 0
IF YES, cla issued:— l
IF YES: s the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book i Page; 3 and/or Document#i
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES 0
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 0
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IF YES, describe size, type and location: i
D. Are there any proposed changes to or additions of signs intended for the property? YES i NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES , NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Nortf ampton
Building Department
212 Main Street a
Room 100
Northampton; MA 01060
'-pht)I*413-587-1240 Fax 413-587-1272 `:I
APPLICATION 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 cotrtple#ed by oifite
�/� Y ` - Overlay Distract
Eltn C11534 � CB15hICt
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED;AGENT
2.1 Owner of Record:
To Y�n(�A (��Oc 101(A Q- , &e�AAU ��f_\ e
Name(Print) Current Mailing Add e s: I(l ob
Telephone }
Signature
2.2 Authorize Aaent:
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
1. Building1!�_ �1 r, ,`-► (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. Date;
Issued:
Signature: ,
Building Commissioner/Inspector of Buildings Date
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136 HINCKLEY ST BP-2006-1009
GIS#: COMMONWEALTH OF MASSACHUSETTS
Man.Block: 23D- 101 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-1009
Protect# JS-2006-1493
Est. Cost: $200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groff: Homeowner as Contractor
Lot Size(sg.ft.): 44431.20 Owner: SCIACCA JONNA
Zoning.URB Applicant. SCIACCA JONNA
9_T_ . 136 HINCKLEY ST
Applicant Address: Phone: Insurance:
136 HINCKLEY ST
FLORENCEMA01062 ISSUED ON:312812006 0.00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL WOODSTOVE
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: D� f t: " A
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Si nature:
FeeType: Date Paid: Amount:
Building 3/28/2006 0:00:00 $25.001761
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo