22D-077 (3) 54-56 CROSS ST BP-2017-0505
GIS#: COMM 0, ;WEALTH OF MASSACHUSETTS
Map:Block:22D-077 ITY OF NORTHAMPTON
Lot:-001 PERSONS CON FR ACT( WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categon: ROOF 1 JILDING PERMIT
Permit# BP-2017-0505
Project# JS-2017-000827
Est.Cost: $10000.00
Fee:$40.00 PERMISSIO '; L'' ;'EREBYGRANTED TO:
Const. Class: Contractor: License:
Use Groun: NORTH EAST SF ',LTY CORP 065521
Lot Size(sq, ft.): 17336,.88 Owner: CH A 1-! T1-IN P&LISA M
nine: U 10 WSP t09E Applicant: NORTH a ST SPECIALTY CORP
AT:: 54 - 56 CROSS 7
Applicant Address: Phone: Insurance:
148 DOTY CIRCLE (413) 739-4333 WC
WEST SPRINGFIELDMA01089 ISSUED ON:10I17/2016 0:00:00
TO PERFORM THE FOLLOWING 15"0. A: :ROVE ASPHALT ROOF & REPLACE
POST THIS CARD SO IT IS VISIBLE FRO\i '. . - REET
Inspector of Plumbing Inspector of Wiring GEM. Building Inspector
Underground: Service:
Footings:
Rough: Rough: Foundation:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY TI1Ir NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy s 're:
FeeTvpe: Date Paid: Alm
Building 10/17/2016 0:00.00 000.
212 Main Street, Phone; '. :1 y.. 1240,Fax:(413)587-1272
Louis Hasshrnuc, i.; _Commissioner
,6f- j'7- 6o5
Department use only
!t City of Northampton Status of Permit:
S uilding Department Curb Cut/Driveway Permit
Oi1 \ 212 Main Street Sewer/Septic Availability
Ns„�cr Room 100 Water/Well Availability
oc0.rtg.,mr" orthampton, MA 01060 Two Sets of Structural Plans
of Hoa"'""P' phone 413-587-1240 Fax 413-587-1272 Pbt/Site Plans
Other Specify
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 completed by office
59- 90 LA'55 cr'2caT Map Lot Unit
FL 02alVdC: , M4 of 0t2
Zone Overlay District
Elm St District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
'TO A& 11 Lica CH++ra&retJ 59-56 ceobs Si-- r1.)nlc&"e • b1 00(..2-
Name
o<.zName(P- ) Current Mailing Addres:
( � “it3 K - 44-tf
I /� lr ., .1 Telephone
Signet
2.2 A horized Agent:
IUd2'TNc715T S PCC/A-cM cu2P 14 r Dory CG2cce L4!. S°r2rdtci 2D ,+ j olvap
Name(Print) nt Mailing Address:
��� C` 9
113) -I3 - `1333
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building (a)Building Permit Fee
/0, CVO „9
2. Electrical (b)Estimated Total Cost of
Construction from(6)
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) G
5. Fire Protection iY q. //y
6. Total=(1 +2+3+4+5) /0/ QD(, - n �
Check Number 7� / _rt-./- ;9
This Section For Official Use Only
Building Permit Number: Date�/�y��/J��/r/� Issued: ,,
Signature: ��y (/GSI �Q -pLd
Bui ng Cam toner/Inspector of Buildings Date
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
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/Finding ever been issued for/on the site?
NO l//( DONT KNOW 0 YES O
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DONT KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
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 O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [p Siding [0] Other[o]
Brief Description of Proposed
Work: 2010vC /44,PNRt. r eirer ft ebP[.4"C Co C d co4rca (or L A-Lc. 01403
-ire A LL IAt't
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
as.If New house and or addition to existing housing, complete the following:
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-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
TCift 4O/L Cfia raw r ,as Owner of the subject
property '/ Cog-
to
,,
hereby authorize i t'3 W 2
to act on my behalf,ft all man rs relative to work authorized by this building permit application.
Signature of• r Date • /
I,
5-761)- .LI /Zac, r r Alc3CGY'- ,as Owner/Authorized
Agent hereby declare that the statements and information on the fore9 Ding application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
S//=.t1 6/1/242Cn
Print Name
/0 /2
Signature of Owner/Ag:t Date
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: S TE-V3:7°
License Number
°io umra4# / ¢ Qi4-1 Mq otan- O11,2-C 72cti
Ad Expiration Date
ei'3) i39 - 4333
S ature Telephone
9.Registered Home Improvement Contractor: Not Applicable 0
NotzteDfs ;S-aitcr> CocA /0 3173
Company Name Registration Number
lv 6 Dor( c/2c Lt w. S, &fcCCLo & Oio&9 7//y/wi F
Address q Expiration Dat
Telephone RIf3) 71A- 4333
SECTION 10-WORKERS'COMPENSATION 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 0
11. — Home Owner Exemption
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,oris 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
City of Northampton 212 Main Street, Northampton, MA 01060
Solid Waste Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as
a condition of the building permit all debris resulting from the construction
activity governed by this Building Permit shall be disposed of in a properly
licensed solid waste disposal facility, as defined by MGL c 111 , S 150A.
Address of the work: 54-510 CLess
The debris will be transported by: et wa SZ
The debris will be received by: Cu+60Pr'C- Cac,t n w
Building permit number
Name of Permit Applicant 0044llemsr ste 'Ott c=oAo
1042-1/6 M
Date Signature of Permit Applicant
'1 The Commonwealth of Massachusetts
g- /,
Department of IndustrialAccidents
E+`' 1 Congress Street,Suite 100
--.
Vitro Boston, MA 02114-2017
www.mass,gov/dia
Workers' Compensation Insurance Affidavit;Builders!Contractors/Eleetriciaxu/I9umbe s,
TO BE FILED WITH THE PERMITTING AUTHORITY,
Applicant Information No ^� Please Print legibly
Name03usincss/Oiganizatioa!1ndividual); h+rid Eft'=' SPEC-tiAa'1 C UC P.
Address: I4 a 'D Urq C(RC:L< weS( SPrKtnKr e tCi-O / AAA . el oe/(
City/State/Zip: Phone#: ei I3) l'.361.- a-(3'3 3 ___
Are you au employer?Cheek the appropriate bun:
Type of project(required):
1.01 am a employer with employece(foil erdtorpertIina)." 7. 0 New construction
2.01 am a sole proprietor or partnership and have no employees working for mein $, ❑Remodeling
my capacity.[No workers'comp,insurance required.!
9. L Demolition
3.01 um a homeowner doing all work myself(Na workers'camp.insurance required.}i t
4.01 am a homeowner and will be hiring contractors to conduct an+ork on my property. I will Id OBuiiding addition
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
pmpdetors with no employees,
12.0 Plumbing repairs or additions
5. I oma general contactor and I have hired the sub-contractors listed on the attached sheet 43.0 Roof repairs
These subcontractors haveemployees and have workers comp.insnmrxu?
24.El Other
6 Wemna),and eh have
doempcens.(Nohow workerichert right otexemption nor MOL u.
152,§t(4),and welwve no employees.(No workers'comp insurance,rer}uvb.)
^Any applicant that checks box 41 must also flit offs the section belowshowing their workers'compensation policy information_
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indionting such.
iContmctors that cheekthis bon must attached an additional sheet showing the name oft the suli contrmetors and state whether or not those.enUties Lave
employees. lithe st oonvactors have employees,they must provide their workers'comp.policy manner.
—
I am an employer that la providing workers'compensation insurance for my eugiloyees. Below is the policy amijob site
information.
Insurance Company Name:___,
Policy#or Self-ins.Lic.#:v „R Expiration Date:
lob Site Address: City/State/Zip,_
Attach a copy of the workers' compensation polity declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c, 152,§25A is a criminal violation punishable by a fine up to$34500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify under the pains and penalties of perjury that he rp/ormationprovided above At true and carnet;
Sienatete: Data:
Phone it: (413) 139,= Li 333
Official use only. Do not write In this area,to be completed by city or tour:official. --
City or Town: Permit/License# ..
Issuing Authority(circle one);
I.Board of Health 2.Building Department 3,CityfTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone'#:_
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written"
An employer is defined as "an individual,partnership,association, corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es)and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships (LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address" the applicant should write"all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions.
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext 7406 or 1-877-MASSAFE
Revised 7-2013 Fax # 617-727-7749
www.mass.govldia
•
I 1
Jr
1
11
\
Massachusetts Department of Public Safety 1 `�\
Construction Supervisor \ {�5 Board of Building Regulations and Standards
Restricted to License:CS-065521
Unrestricted-Buildings of any use group which contain Construction Sup_ervisor +` mss
less than 35.000 ci b' .feet(oot . .::f
enclosed space
� �
STEVEN F BARRETT
a0 N_4THPNAL s'irA -
iE_CHER06 i61 MA OICRt'. `
_ _ Fa lu[e[o_iog Code
possesscurrent edition ctionofssach — '--- '- - -
---" ---- - - _ " Commissioner 01/258018
Stat Bustling Codis cause for revocation of this license. _
OPS licensing mtonnation visit W W W.MASS,GOWDPS •
Q./ke `0;9/ ea-Toi/ween c/ H oadeaea,
59.,
Office of Consumer Affairs and Business Regulation
_ 10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 103713
(ti Type: Private Corporation
� - Expiration: 7/14/2018 Ira 419291
NORTH EAST SPECIALTY CORPORATION
SHARON TARIFF - '
148 DOTY CIRCLE
WEST SPRINGFIELD, MA 01089 " -
Update Address and return card.Mark reason for change.
,cn, f> 2e14 0501 t] Address ❑ Renewal 0 Employment p Lost Card
diL m„saeal&n/C1ti(m rckoati
Office of Coaeumer Mfairs&Business Regulation License or registration valid for individual use only
I '.6 HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
ppI Registration: . 103713 Type: Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
`ff. ^
y Expiration: 7114(2018 Private Corporation
Boston,MA 02116
NORTH EAST SPECIALTY
NESCOR •
SHARON TARIFF
148 DOTY CIRCLE _�i._ c4w:, C r 4
NEST SPRINGFIELD,MA 01069Undersecretary — Not valid without signature
/'h NES00-1 OP I0: DS
A4---- ' CERTIFICATE OF LIABILITY INSURANCE DATE YYYI
071191201$
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: It the certificate holder is an ADDITIONAL INSURED, the policy(lesl must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the poll y,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
Certificate holder In lieu of such endorsement(s).
PRODUCER -NAMEA°T ,1 Raymond Lussier Ins Agoy Inc
LI Raymond Lussler tna Agcy Inc PRONE
FAX
Park Avenue,Suite 8 A1. ho,EM(:413.737-5359 (AIC.N4 413-732.2027
PO Box 499 aooaiSs:InfOgfuSSIerHISUranCe-Com
West Springgeidt MA 01090.0490
Q Raymond Loathe Ins Agcy Inc INSURER(%)AFFORDING COVERAGE NAICI
INSURER A:Western World Ins.Co.
.INSURED Northeast Specialty Corp mammas:A.I.M.Mutual Ins.Co.
Nestor INSURER C:Safety Insurance Company _ 39454
148 Doty Circle
West Springfield,MA 01089 INSURER D: ._
INSURER E'.
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED OELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS.
EXCLUSIONS
$$II99 TEMXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMP'S SHOWN MAY HAVE BEEN REDUCED BY PAID
.LTR. OF INSURANCE ry6O UL ayY, pl POLICY NUHO 'A¢
ER (.MM(t} (M.YLODIYYEN}- LIMITS
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMHMADE `xJ OCCUR NPP8326163 0311812016 03118/ 1}ENF TU
2017 PREMISES(MAbt I°Ee occ.,gncel s 1001000
MCDE%Fonyon09EWni $ $,000
—
PERSONAL&ACV INJURY $ 1,000,000
GENT AGGREGATE:MIT APPLIESPFa'. . . GENERAL AGGREGATE S 2,000,000
POLIO PRC LOC PNODVCTS.COMPIOP AGS $ 2,000,000
OTHER. _
AUT4MORRELIABIAW nittirotTNGLEINMIT $ 1,000,000
C ANY AUTO 2433825 03/11/2016 03/11/2017 BODILY INJURY(Pet person) $
ALL OWNED X SCHEDULED
1001LY MRY(Ps'O 4 F S
AUTOS
PNaRRTYpAMAGEX MED AUTOS X - WNED,AUTOS
a 5
AUTOS
$
UMBRELLA LIAO OCCUR EACH OCCURRENCE $
EXCESS LBO _CLAIMS-MADE AGGREGATE $
Dr0 RETENTIONS $ ..—
WORKERS COMPENSATION 6LRTUTE EA H.
. ANO EMPLOYESS'LIABILITY
S ANI PROPRIETOWPARRJER2%ECUME YrN VV;CS003062018 01/09/2015 07103/2017 M.EACH ACCIDENT 1 10G,OOO
MICEPo EMBERE3TAWEOT 1 NIA 100,000
(Mmftloryln NH) E.L.DISEASE,EA EMPLOYEE T
rr yesOEMs unne SODOOD
DESCRIPTOR OF OPERATIONS OaIOn' �y EL DISEASE-POLICY MC $
--
DESCRIPTION OF OPERATIONS I LOCATIONS I VEW0.E9 (ACO RD 101,AdpHlaner RO MME Soheduls,fly be}MM MIll merit sotto It required}
CERTIFICATE HOLDER CANCELLATION
CUSTOMS
SHOULD ANY OFF THE ABOVE DESCRIBEDPOLiCIE9 EE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTCE WILL BE DELIVERED IN '
ACCORDANCE WITH TIE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
. .. J Raymond :master Ins Agcy Inc
1 e-
-"'" (D 19852014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014/01} The ACORD name and logo are registered marks of ACORD
City of Northampton
�� 5`
Mass
achusetts :+s /‘ctm
x
d r�;{4L DSPARTMEN1' OF BUILDING INSPECTIONS �//
�' + 211 Nein strut . Municipal Building r \
�""� Northampton, NA 01060 k 4
Pi 'In`
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as his/her
construction supervisor. 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/footi gs (before backfill). sonotube holes(before Dour).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 DFI AY 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