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DEPAaTMENT OF BUILDD-IG INSPECTIONS
INSPECTOR 212 Main Street 0 Municipal Building ,
5�
Nortliampton,MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sups-,,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�ui1 Ing department for the City of Nc rthampton wants-any person(s)-wh-o-seek-t-o
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 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 owner/resident' signature requesting exemption)
I will call to schedule all reAuired building inspections necessary for the building permit
- - issued to me-
Date 4I I S
Address of work
location— �
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c DEPAR i MEITr OP BUILDD\IG INSPECTION'S
212 ATain Strcct - h-funtcipal Bn116;ng
j Norlhamplon, ASacs. 01060
_ WORIMEIZ'S CONITEICISATION MSURACE AFFMr1ATI-I'
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(liccnsxJpc�miff----)
%vI h a prtncipa! plat-- of busipessfresidence at:
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(hbone�=}
do hereby cerdi -, under thc.pains and penalties ofpcgury., :hat
j ( ) I a m an employer providing the folio%vinp-lv.,orkcr's comocnsa60? coveralc for my
emplovecs ivorldng on tliis job
i (L=Uj-=B=Corr si}) (Polio:NU-nab:r) �:pirtior, D2=)
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( ) I am a sole propr;ctor, general contractor or homeowner (ci cie one) and have hired
the cont:aCtors Gsta,i below Tgbo hzve the foboL%U' p- worker's cor2ioep_'�anon pokles:
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(Namc O- COn'^CiOr) On umnc- CoInpan)-iPobc NLLMh-:-) �':J1FJ O l D IIC)
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I (N me of Conarenor) (lnsarane Comoamlipolicl Nuncrr) (La-DIrtion Date)
(Name of Coamclar) (Insuranc:CompanyfPoucy N mbzj) (EXpir6e0 Dalc)
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Ogamc of Contractor) (Insurance Compazy/Poticy Numbs) (Ecpum6on Date).
(al:��: i�oczl$cC,if necezr_�w a�cly�ia(ortoo pc'"'n' w all ooe7-to-s) -
{ ) I am:a sole proprietor and bave no one working for me.
(' am:a home owner perforrtling all the work myself.
NOTE:Pl-•r be Z-.Xrt tst wJc -bo cc=plcry pczom w cio - •- csrjoc a rapair work as a d-.c --Z of
janC taocz tb:n L4cr_%rs in N+sicb the bo=o we rceid=or oa the IIou d,z,�purtro_�tbcc o�:wC —Uy occed cd to be
j ctploy=s u f the--i ;> -cc pa(GU1I52.=1(5)�. bye 6omrnova fcs c Gc---«P=Mh=1 LL-
IIcpJ r+-^••of na-=Ployx under dh Wockoe,Co�oo Aoc_
I r+r>ac�t+ad d",x Dopy oC thi.micas o y bo foc. .rded to tbo DeQ�of ja& ricl Ac�dCW'.�'OILoe or 1—for th.
Dove a se v�Zc=ioa and ttu L ilurc to seat bp�t�und,'S =;oa 2.5 A or),(GL 152 eaa I�d to the inipcxitioa of c imiaal pec%164=
oeasi`i o of a fine of up to S 1 X00.00 endtoryo or up to Doe year r.�d ei�11 prn+l'ua m 6c form of a S�W ori;O+-dc nod a
i fry O(S I DO.00 s d--y aPic:a u:,--
- - - .. Foe dep.rsaa�-si use only
7 PcSIIU[Nttmtxs - -
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S i gaat lm of LiccnsccfPc nzu --fie -
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SECTION;8-CONSTRUCTION SERVICES +
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
ae rs"lle amn" "" °mno ' a Not Applicable ❑
Company Name Registration Tlum 6-r -- -"---
Address Expiration Date
Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCE"DAVIT(M.G.L,-c.i52;_§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...... ❑
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 y '
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check'all applicable)
New House ❑ Addition ❑: Replacement Windows Alteration(s) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[t�j
Brief De r' ton of ropos d i
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
i ife 'Ouse a OUR e tf lQUt�r
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 AUTHQRIZATION-TO BE COMPLETED "WHEN
OWNERS AGENT'ARCONTRACTOR APPLIES�FOR BUILDING::PERMIT
l 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.
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Signature of Owner Date Now
l 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.
`CGS C
Pn Name
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Signature of Owner/Agent AI Date
Section 4. ZONING All Informati6h Must Be Completed.Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This colurnn to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front L
Rear
Building Height 77-1
Bldg.Square Footage 0110
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume,&Location)
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A. Has ' a| Perm�/Vahmnue/F ndi ever been hsuedfor/on the sha?
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NO 0 D�7�OW �� YES ��
IF YES, dotaisuue&
IF YES: Was the permit recorded at the Registry of Deeds?
NO K j DON1KN0m 'ES
IF YES: enter Book Peg and/or Donument#
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B. Does the site contain u brook, body of water orwetlands? NO «���� 0007KNOVV v�� YES ���
IF YES, has a permit been or need to be obtained from the Conservation Commission?
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Needs tobambtaioad «~~� @�t��med �~� 0ota [ssu�d''
�~� t~� '
C. Du 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 propmrty? YES 0 NO 0
IF YES, describe size, type and location-
E. Will the construction activity disturb or filling)over 1acre or isdpart ofocommon plan
thow@disturbnver1onre? YES NO K 8
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Nortpampton
Building Department
212 Main Street
Room 100 a .
Northampton; MA 01060
phone 413-587-1240 Fax 413-587-1272
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 becompieted by office
Ft OLevicc 4t4
Zone- ve�lay Uistnct
Elmer Distru t GB DGStnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Q.-ic tey 411d- 6:-i;jle. 2���� y4V /10
Name(Print) C t Mailing Address:
i� -11 A 016,0 "14 }- 3A,Z
Telephone �c
Signature Y _4 9 01
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS?
I em Estimated Cost(Dollars)to be Official Use Only
completed by ermit 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
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6. Total=0 +2+3+4+5) Check'Number
This Section For Official'Use Only
Building,`Permit Number; Date
Issued:
Signature: ,
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Building Commissioner/Inspector of Buildings Date
269 RYAN RD BP-2006-0523
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29- 142 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0523
Project# JS-2006-0776
Est.Cost: $1000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 11717.64 Owner: BOULEY MICHAEL C&HEATHER M
Zonin :URA Applicant: BOULEY MICHAEL C & HEATHER M
AT: 269 RYAN RD
Applicant Address: Phone: Insurance:
269 RYAN RD O 584-6400 O
FLORENCEMA01062 ISSUED ON.111812005 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 LAYER
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 Si nature:
FeeType: Date Paid: Amount:
Building 11/8/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo