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DEPARTMENT OF BUILDING INSPECTIONS � -_ �_ /=
INSPECTOR
212 Main Street • Municipal Building 7
,,
Northampton, MA 01060 •
e
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 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 backfilp,
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
1, 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
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DEPARTMENT OP BUILDDN'.0 INSPECTIONS
212 Main Street. ' Municipal Building
{ Northampton, Mass. 03 060 r'
\V RiCEIZ'S COMTENSATION NSURANCI✓ AI FUM.VIT
(lierns )
\kith a principal place of business residence at:
A.4 42.e. /��
L(z t r �i1�`�i�f JJ , C (Ph one� -) /� 327-
(s t/cityfdZ lffatp)
do hereby certify, under the pains and penalties of perjury, hal
{ ( ) I am an employer providing the followings orkcrs corn nsaron coverage for my
•
employees worng on this job:
(L*lsur - mac Cocit r) (Polio: Nu_nl cr) -- (E :pirzt or. Date.)
•
( ) I am a sole proprietor, general contractor or homeowner (ci cie one) and have hired
the conu-actors listed below who have the foilowiog worker's compen poi ties:
(Name of Co „ ^cor) (In uranc^- Cornp11)yiPoUCi N1 mk:) i uon Drac)
(Name of Contrctor) ansuznec Company Pape}• Nuncer) (L»irtion Due)
(Name of Connacio:) (Lasurancn Co mparry/PoLicy Nurnb:-r1 (Expiraon Date)
(Name of Contractor) (insurance Comp, rry/Poticy Numb•:.r) (Etipitadon Date)
(attxh sdd ocn.t chcCif acc_ V to ¢>dud_ iafoct;v:ioa pctainins to .11 c `r--_2 3)
(( -a sole "pr opnetor and have no one woring for me-
( ) I am.a home owner performing all the work myseLf.
NOTE: ptr-.- be .9'2= tt„• w'c1e boc000woon ' oo =ploy pc-sots to do c.xiciczucc, �= �� c ncoir work oa a d "_n: =r, of
ant tnoct tiL.c t' rv-_ ttru in wbieh the bocacowocr raid= cc cc the crou.ada wparten_st tbcdo e c cot c3.�elly ooc= d-ni to be
eisploycs uodc the .+ukd: re-., Aa (GLt152a 1(5)). c-pPtin aoo by a bomcowoa far c ttez. cc pecan ce.cy ec.d,• occ the
legal n=^ or ca c � rloyx under d>o Workmen comgam.lioa Act-
1 uoaczsr-od to a copy of tht. ca.t.comt tn..y be focward..d w the Dc¢.rtmc t of 1 • Ac�dca� Office oC k�u+°c° Cor th.
oovca vc-iGcaioo =ad Qu f_ih 'o to r.avrc'covtza =6C' sccdon 25 A of MOL 152 can led to the rzznsaioa o(c'=i p-7"1t;cs
cocci-sag' of a rare of tep to S 1.500,00 sod or itraprboarrsxzza of up to oae yr_r xnd aril pcaitia is t .c focal of a Sorts Work Ord Ordc .ad -
rlco of S 100.00 a d y aF,aiaA me
For ° + _ �, u.c on77
permit Number _
.4..litrrid / 1 map: _- Lot " J
sI SignaLUrc ofd .- scilF'cratiticc 733te -- I
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SECTION 8 - 'CONSTRUCTION SERVICES ,. - °I
8.1 Licensed Construction Su a visor: //�'' -- f , Not Applicable ❑
Name of License Holder : ,�4 , em u', C.,_ ' Q , 6 - / f /
License Number
/Cif /` fr !' 4 el/0z 7 /f /y 6,
Address - Expiration Date
.
gl,/ Signa Telephone
.- 2e e i 4 ere ome' ' in rnre cr .:Von re o - _ 4 4 - , 4 ' h , , " Not Applicable ❑
• company Name Registrat' n um r - -- ___ -__
l /2,/se7( r a / i
/ 7
Address Expiration Date
r4l / 11 4 / C�L1 /4, Waz Telephone / '&5527,24 96
SECTION 10- WORKERS' COMPENSATION INSURANCE:AFFIDAVJT (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 ermit.
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 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
P"
• •
SECTION 5- DESCRIPTION OF PROPOSED WORK (checkcalt °applicable)
New House ❑ Addition ❑ ;- Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [ ther [0]
Brief Description of Proposed V -1T J`;0E 49,- .r4b■ve7 al lzX6' Cne
Work: C6 4 5740
Alteration of existing bedroom Yes t,./4 Adding new bedroom Yes 1../
Attached Narrative Renovating unfinished basement Yes _ L - No
Plans Attached Roll - Sheet
�£-' ` ; �f -5:,g, � 3� z �- �..,: r "�.'" �"`.w �.. c`,,.,'"`' =i� '�„'�'''�. �,^
6a -i ev1 ouse~° n �oi a d #ionu#i exinc io. stnq� =:carmpieteihe fo1IGWI �q:
a. Use of building : One Family Two Family Family Other
b. Number of rooms in each family , unit: �` Number of Bathrooms 3
c. Is there a garage attached? //4
d. Proposed Square footage of new construction. Dimensions e./, /r c.4
e. Number of stories ? /
f. Method of heating? A4/4 alJ/ Fireplaces or Woodstoves M Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction 0I �
i. Is construction within 100 ft. of wetlands? Yes L' No. Is construction within 100 yr. floodplain Yes z--
r
j. Depth of basement or cellar floor below finished grade 7
k. Will building conform to the Building and Zoning regulations? 1- Yes is l% .
L Septic Tank City Sewer (/ Private well City water Supply Z/
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT. OR CONTRACTOR APPLIES FOR iBUICDING PERMIT -
I , as Owner of the subject
property 6:8,40 � � � t
hereby authorize /�. D / 5
to act on my behalf, in all matte relative to work authorized by this building permit application.
4 #gnatd:f20 Date
- -- ---- - - - - -- - - - --
I J/ 2' ( 6 , as Owner /Authorized
Age t hereby pclare that the s atements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed un r the pains penalties of perjury.
/
Print Name j / _
" f '.....i .4k' -1 •11.
Signature of 0 "gent Date
• . ,. 4.
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 I _ - I '
I£ #1 i
Frontage
Setbacks Front s ? I 1
1
Side L: i R: i L: R:I I
Rear 1 -- _
Building Height . .. , • 3 - j
Bldg. Square Footage L __ % 1 I 1 ( i I
Open Space Footage % {{
(Lot area minus bldg & paved 1 I ( I i 3 i ( f
parking) -
# of Parking Spaces I
Fill: , 3 f
(volume& Location) i
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW YES 0
1
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 3 Page' and /or Document it;
B. Does the site contain a brook, body of water or wetlands? NO ®DONT KNOW 0 YES CD
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 0 NO
I
IF YES, describe size, type and location: j
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 NO
t 1
IF YES, describe size, type and location: 1
E. Will the construction activity disturb (clearing, grading, excav n, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 ,. NO
1
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
.
City of ilding Northampton _..
�� _. w Department ;g a , f � 4°' + a � . [7-, IJ V/ .g F 212 Main Street e �
--,' ; Room 100 ° ;�,= e �, � � _ �,
L F n hampton, MA 01060 . �� �
phone 4 - 587 -1240 Fax 413- 587 -1272 . s c
i ,,7 ,
4
APPLICATIOM TIQ(CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
Tfai s e c tion to i.e coni by- o ffice
1.1 Property Address: ^,,',£ , "~
;26 Property
sE7 G�. ' s - � -,' fal
` , €,? , � / " Zene y Overla D
f`7/ C.`/ I � wry s �„ �c i as `*t r
7 s ',g >a a ..z s
e e ; 1rirSf Dis n _ CSpstrit
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT .
//-P-t
2.1 Owner of Record:
N me (Print) Current Mailing Address
j-o r�� Telephone
S�gnat
2.2 Authorized Agent:
f
( :J /C. /1''r7 / � c t �
Name (Print) Current Mailing Address: Of1/
/C.-..?0,-1...‘i-4-' '
/ - -Y2 7
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item - Estimated ) to Official Use Only
completed by Cost permit (Dollars applicant be
1. Building
"V.-4,2y, c5 9 (a) Building Permit Fee
2. Electrical (b) Eate r o
Construction n Total from Cost (6f )
3. Plumbing �_ Building Permit.Fee
4. Mechanical (HVAC)
5. Fire Protection _
6. Total = (1 + 2 + 3 + 4 + 5) Check Number
Thi For Offic Use Only
Building Permit Number Issued:
''
Signature:
1
Building Commissioner /Inspector of Buildings Date
26 " :' :t":! - ;: - W" , t BP- 2006 -1069
GIS #: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -00
Permit: Building
Category: BUILDING PERMIT
Permit # BP- 2006 -1069
Project # JS- 2006 -1578
Est. Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: CORBEIL ASSOCIATES 119492
Lot Size(sq. ft.): 6185.52 Owner: MONGEON EUGENE J & BEATRICE F
Zoning: URC Applicant: CORBEIL ASSOCIATES
AT: 26 TRUMBULL RD
Applicant Address: Phone: Insurance:
148 PARK ST (413) 527 -9286
EASTHAMPTONMA01027 -2162 ISSUED ON:4/7/2006 0:00:00
TO PERFORM THE FOLLOWING WORK: RESIDE WEST SIDE W /CEDAR SIDING
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 4/7/2006 0:00:00 $25.001773
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo