32C-326 �gttAMp�,
of 'dazt4alli Stan
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n DEPARTMENT OF BUILDINQ INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building s,
Northampton, MA 01060 ,
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as i:is/her construction sup,-': .� sor. 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 backfiIi),
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.
Tf 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
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o DEP/1RTMElJT OP BUILDf'�\,G rNSPPCT(O1.'S -
212 Alain Street Municipal Building
Norlhamplon, Mass. 01060
`VOR CI:R'S COINOENSA:TON UTSU -A-NC- Al,
(1i cro_secJpermi etcc) --- —-
\=11itb a prblicipal place of business/residence at:
i1 4F.D 6-,I-kg,5 (.!491C yyi D/093(phooc..
I "U 'an)
do hereby cerdi ., under die pains sad petiilti-e' ,of perjury., .1h:n
( ) I am an employer providing the followine worker's comocasadon cove^ge for Iny
emplovecs wor 3ng on ties job:
(Insur-anc Conn:m') (PeLic: ivu--n!D,--r) -- (r:pir�uoc DPI-)
( ) I atn a sole proprietor, general contracor or homeowner (cu cie one) and have hired
the coniractors listed below who have the folloW*P, workers GociDtasz6on policies:
\`+BIDe 0, anmicwr) (1rlSLr-ancr- Cornoan}•rPoue; Nurrlrc:) (E':J1nJuon l)alc)
(Name of Coacramor) (Insurance Company/Po!ie; umccr) (ExpLM.6on Date)
t%NaMe of C0aa2m6;) (inS raocc ComT=)-fPotig- N.,Imbcr) (I:--,:QL'M600 Dalc)
(Name of Conrramar) (ILUUran Comcaay/Policy Number) k -ration Dar).
(a[ISCU=ddi::•ocmJ 6.cc.ifnccaary to c�dudc infonniaoa pertn to.11
r
( am a sole proprietor and bave no one woribng for me.
( ) I am..a home owner performing all the work myself.
NOTE:plc_x be ata-irc 12"utJo wbo c:mplay pc-.om to da - cas c oo c rr,,xu.Drk oa.d c1L of
mot mote r1:o throe t--Jij in tc},neb the bornoo+voer raids or ca the p-ouoda zppt:.rtcn=tbe�-u zr oa G=r-Uy oc%-.6-nd to be
=*<)y tic the w�,;=A-j gym Aa(GL152-=l(5)�applica.6aa try a boa=-=far a lice__oc pamn ray c-;d—rbc
Ic$il n»,.of en exployx coder dro W OAe a Coa�yea3at Ad
1 uad=w ad d>d a oopy of Chia= rs—y b-fo,-a.orded to the pcputmat of A, A� _ Off o0 of 4u+noco for tbw
oovcrn.E;c vCirc=7 Ca=id UL--t U==to Lc=m lcovcinse tmdcs sccGoo 25A of MOL 15'1 on led to the of eimiail pc i -
cooaiz of a fine of tW to S 1 500.00 and/or iazpriyoamern orup to one y=r tad aril peaatie;0 6c form of a Slop Word Orde sad a
fin of S 100.00 a d y t&IIin11 t>x
For dcp.,r -�• v.c oary .
0 , PcTmit Numbs-r y
V••�(,///V�� AaU -7 i ten-__ Lor
Si can of Li crnuucc We -j
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
s
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
g Rec[vs#eyed Fome fTrapr'oi�ementContractoF zv' Not Applicable ❑
a
aK�S ILtft�ls��' /'yjt5 cQn,�-r��fy' /39�4p
om anv Nam « Registration Number
it "Pro
Address /1-v Expiration Date
Telephone
SECTION 10-'WORKERS'COMPENSATION INSURANCEAFF111)iT(M.G'L..c.1"52,:§,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....... UK No...... ❑
figg
- 011 UK An
The current exemption for"homeowners"was extended to inchide 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_o_u�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-vear 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
SECTION 5-,DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Window's Alteration(s) ❑ Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding[0] Other[[:1]
Brief Description of Pro o r � .04k y OIV
Work: 5fPi p D i
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa�tfeufioase a Ladd►trQn#o ex{sticaoastnclo p#e Ciflyurinq:
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=OWt�tER?AUTHORIZATION TO BE COMPLETED WHEN
_�.9 �_ . � � . .
O::WNERS"AGENTOR;`CONTRACT.OR;APPLIES FORBUILDIN;G PERMIT
as Owner of the subject
property �-
hereby authorize NarK
to act on my behalf, in all matters r ative t ork authorized by this building permit application.
Signature of Owner Date
('s as Owner/Authorized
Agent hereby declare that he statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains an enalties of perjury
r
at�Cr
Print Name
Signature of Owner/Agent Date
`
^ *
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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
I Frontage
Setbacks Front
Rear
Building Height 7--7
Bldg.Square Footage
Open Space Footage %
(Lot area minus bIdg&paved
#of Parking Spaces
(volume&Location)
A. Has oSpecial Perm it/Vahonoe/Findi ng ever been isyuodfor/on the site?
�� ��
NO x_��� DON7KNOVV \_� YES �,�
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry ofDeeds?
NO �� � D
� 'KNOW 0 YES
IF YES: enter Book Page; and/or Document#'c
B. Does the site contain a brook, body of water orwetlands? NO 0 DOmTKNOVU YES x~�
IF YES, has o permit been or need tube obtained from the Conservation Commission?
Needs tpbeobtuined Obteineg �~� Date
�
�_/0 '
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: |
D. Are there any proposed changes to or additions of signs intended for the property? YE3y~��� NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre orieit part ofo common plan
that will disturb over 1 acre? YES NO [ l
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
� 4 � De�artrnent„bse�on�y ��
City of Northampton atus o1 Peml
Building Department �n
212 Main Street
Room 100
rti ---------------
Northampton, MA 01060
phone 4:13-587-1240 Fax 413-587-1272to
f.� 7,,,
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 11=SI.TE.INFORMATION
1.1 Property Address ° Th ection to h
e completed by office
Maps Lot Unit
�( r
1 1
�.O I'�'�11�Ncp 1'o!t I'll/� Zoae; Ovelrlay Drstcrct
ElrrrSDastntf „w' DBDisfrtct
SECTION-2-PROPERTY-OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
tt'ZUl1i'�.0 yTe �
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3---ESTIMATED:CONSTRUCTIOWCOSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by--ermit a- licant-
1. Building (a),8uilding�Permit`Fee
2. Electrical (b),Estimated Total Cost of
Construction fi-orn(6):
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=0 +2+3+4+5) Check-Number pl
This`Section For Official-Use Only
Building Permit Number. Date.
Issued:
Signature:
Building Commissionerlinspector of Buildings Date
16 HOCKANUM RD BP-2007-0606
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C-326 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Category: BUILDING PERMIT
Permit# BP-2007-0606
Project# JS-2007-000892
Est.Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Grouu: M & S CONTRACTING 139298
Lot Size(sq.ft.): 1393.92 Owner: LAPERLE JOSEPH E
Zoning:URC Applicant: M & S CONTRACTING
AT. 16 HOCKANUM RD
Applicant Address: Phone: Insurance:
11 GRASS HILL RD (413) 665-8161
WHATELYMA01093 ISSUED ON.1112912006 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE ROOF
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 11/29/2006 0:00:00 $25.00112
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo