38-064 (4) -
8
DEPARTMENT OF BUILDINIG INSPECTIONS
INSPECTOR '2'12 Main Street • Municpal 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 has/her construction sup,°: :.'>or. 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 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 r'.egulations. 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 injpection (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
r
�°
0-�[ 3 .af 01111a11133foi�
DEP/tRTMENT OF DUILDr),�TG INSPECT1011'S 3
212 \fain Strect Nfunicipal Budding
NorLhampton, Mass. 01060
W0M<Q R'S C&IVIP ;NSATIO.N MSU3---NCE AI
%viLh_ a principal place of businesslresidence at: ---
(1-hione_)
(s�tralc.'t-J/SzL3J_Clzjp)
do hereby certify,, under dic.pp!ns and penalties of perjuj-y hal
( am an employer providing die foilowine'workerjs comocnsada, cove-fie Lor Im
elLhlovccs woriong on dus job.
(—E:pim or D:rn)
( ) I a.ai a sole propreior, general contractor or hou-ieovrDer(c tie one) aid have hired
he coouac#ors Lsed below who h2ve, the folloviicg workers coaoen_a:,on pokies:
(`tNalnc Oi CG:=c-,Gr) (1RR!P I1 t;: Compan)'/Pout'{ NIUM1�G-) Datc)
(LN me of CoaTzcior) (fns e- ComranvrPo!ie; \tmcsr) (Eapir:lion Dile)
(Name of Connaclo:) (Insurance Com /Pot el ti.rs r) (Exairaon Daic)
(Nl-Mc of Connacor) (Irsuran Comr.-_ny/Policy Nunb-,Ir) (Et�LCa�on Date).
(aII� iCoc!L�cC,y znc . to c�cvcL�uafor�oo.pctain:-o6 w aU me-.tts.)
( ) I am 'a sole proprietor and have no one wor-idog for me.
( ) I am,a home owner performing all the work myself.
NOTE:pit lx aar q jzijc(zcmr �c-a_,CAGY Prat=t.o do a= c.==ao c-r,cru work on.d.•< _--Z of
ant Mccc t tL-M L J in t---izca tix oomoowmn=read..-.or oa Lb, zypu.-L4 =ut—^ �.ax C=-L',+oce-d. d o Ue
czployca undo the,..�- ,� -...:ca A,=(GLA 52....^.1(5)}.=ppU=. oo 6-j a hom o> =fc z leo.,a perT r ca=ydt1-
V-=-of ca c�ioyx uodcr d,a Woh,ola C,oczpo,_4;,,AcI
_ 1
'DZt--az d dt-A a ropy of thaa c=tc %m y bw f---,d-,d b tho Ccq.urt_-xx xr at Iu�rrie!Aec �'Gffioo of Iray.00a for thn
oo7c -�C:=on=d Ltu f i at to S.=='co"cTasc txa c sx on 25A of),(GL 152 c=L d to tbo iaap2ioa orcimicA pc' W c
ooa;i.=tea or.floe Drop to S I_}O .00 i= rc or up to o«yc=.-end cii1 peutia to be form of s Stat Work Qrde and a
fig a(S 100-0,0 z d-- t&xic:a me
For
f Pc='t NuanLX---
Lot
SiPflatom of Lic=,sccIPcn uu= >J=Ce A ¢.
SECTION 8-CONSTRUCTION`SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address �t ;� Expiration Date
1 r a
Si nature Telephone
Not Applicable ❑
:�Reaast�red't�C`ome_iesip�veme�t;Oatitra�cfar ���-�.,- ,�"`--s-�;� �-
Company Name Registration um er --__
�Address Expiration Date
Telephone �M+�1- t�ii
SECTION10-WORKERS'CQMPENSATtON I1�tSIRANCE�FFIDAT(NF`G. ,c.152x: 25C(&}�.
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(?)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 farm 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
t
SECTION 5-DESCRIPTION'-OF PROPOSED WORK(check all.applicable)
New house ❑ Addition Replacement Windows Alterations) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks (Q Siding[0] Other[0]
Brief Des nption of Proposed
Work:
Renovating unfinished basement Yes
Alteration of existing bedroom Yes No Addingnew bedroom Yes No'.
Attached Narrative g No
Plans Attached Roll -Sheet
s . �1ew'., ouse-an �racCd� >� fa ez st>«i` uslinaMom, te�-l�he�fattQur��n
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BECOMPLETED 1tVFiER
OWNERS•AGEN ORcONTRAGTOEt'APPL-IES:FOR BUILDING=:PERMIT
1 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 Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of m'y knoTdge
and belief.
Signed under the pains and penalties of perjury.
Print Name
Sign atur of Owner/AgentDate
Section 4. ZONING All Information Must Be Completed. Permit Clan Be Denied Due To Incomplete Information
Exiling Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
---------------
Frontage —
Setbacks Front ..
Gam_
Side L:' R:' L
Rear
Building Height _
Bldg.Square Footage -- %
I
Open Space Footage % �®
(Lot area minus bldg&paved
arking
#of Parking Spaces
Fill:
(volume,&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Pages and/or Document#
B. Does the site contain a brook, body of water or wetlands' NODONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 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:
E. Will the construction activity disturb(clearing,grading,ex 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.
'r Qepacfnren usegQnly � �
b
�r `City of Northampton Slaf�tal=Ferrrtrt~ � � ��
a
�'u�.Iding Department CetrCrxt(Q€t�ze�nca}isFesm � ��
�,
h Main Street se�,verfsepC;4 ai[a6irEr
om 100 GtfatereIAyarfa6iltf3r� @
No'ham ton; MA 01060 Tota Sets of Strucfetral Pfans ,� �
R's phone 4,1-,'l87-1 0 Fax 413-587-1272 Pfot/Siteans .
O#her Specty�
APKf6ATION T&c STRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTIO1 .0 -SITE INFORMATION
1.1 Property Address:
Thrs sect[orrto 6e completed byafft-1
-
Z"oris
Eim St Distrrct :r .. .CB D�stFicE '
SECTION 2-PROP ERTY`OWNERSHIP/AUTHORIZED AGENT-
2.1
NT21 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: (�
Name(Print) Current Mailing Address:
Signat ''`e Telephone
SECTI8N 3-ESTIMATED.CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (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 Sec#forr ForOffrcial Use Only
Date
Building Permit Number: Issued:
Signature: r
Building Commissioner/Inspector of Buildings Date
s
File#BP-2005-0642
APPLICANT/CONTACT PERSON Kevin Netto Construction Inc.
ADDRESS/PHONE 90 Southampton Rd. WESTHAMPTON (413)527-3168
PROPERTY LOCATION 184 EARLE ST
MAP 38 PARCEL 064' 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
Typeof Construction: RENOVATE INTERIOR FROM SINGLE TO 2 FAMILY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 001317
3 sets of Plans/Plot Plan
THE FOLLOWING TION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION P SENTED:
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: § 14 — [o ' �� �
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Garb 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 Commis
Signature of Building Official 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.