35-195 (4) ¢•Stif+MP�.
Crxfv of Nart4aillptau L
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�IUSSHC1tliSCtf! -
t DEPARTMENT OF BUILDING 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 780CMR 108.3.4 to
act as his/her construction sups.- ,-i sor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a die or two farm 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 building department for the City ofNorthampton 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 backfll),
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 occupancv
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
Dates
Address of work
location
0� '
A £ i�j7a�crltntrtta'
W DEPAtRTMEN? OP BUILD0,10 INSPPCTIOI.'S -
212 Alain Strcct Municipal Building
Northampton, ATass. OlOGO
wort=_Rls CO,YTENSA'170N G'tSURA_NCE ?.1fiIPli���T
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I
(li�'xJpc-r�7lttc�)
%lrl th z principal place of business residence at: - -
(phone')
1
do hereby certify, under tlic.pzint :mod penalties of perJury, -hat
{ ( ) I am an employer providing the Following,!,.vorkes comocns-;ion covervgc nor lny
emplovices ivorlong on tins job:
i (L=u.r-mac Comz=v) (Polio: Nti-mb-cr) -- (r_:-nir`tior. Dpi-)
( I am a sole propr,ctor gcocral contraaor or homeoaoer (ci cie one) and gave hired
the cona-actors listed below vgbo have the `olio vine workers comnen�non policies:
("INMe Oi Contmaor) (In-urzf1c; Compant -il?ouc D.11c)
I — -
(N�c of Con>raor) (Insa:ranc;. Compare i?oUc \. -mc_r) (Lipir ion Date)
(N,me of Coa=cior) Ozsuranc Company Ipol;c tvasbu) (�-xpirdon Daic)
I -
(Namc of Contrar-tar) (lasuranct Comean-yipolicy NumLyz) (E_xp r don Dale).
(.IISL�I��oo.l�cC,ifac�i-y to incud_iafora..SOO pctuasa6 to.17 out-to-�) -- - _.-. ._-
i
1 ( ) I.am_a sole pr-opfietor and have no one wor'dng for me.
11 ( ) I 2m..a home o wner performing aU the work myself.
NOTE:pl=.-be ewue tfi.•..t�Je bomeoµvc a.bo c=:plaY pc-.4=to do -c,00 c rc;mLa work on c dTlL^Z of
CDC more than =t tL,is%x-b3cb the bomo -ac r%=d�or oo th c p-ocr�c4 a7psttcn_r1 tbeea :ax C=�:.lty Deed--cd 10 he
c i70cr-s �c the Cn=P- _,:ea Aa(GUI 52,=1(5)1 optic==by.bomrn.aae fc c Gc=-or pe-mn r✓y c ids the
Ic-®.t eulsc of a=e—`plover under tlro Wocl•�ola compom.tioo Act
� [ttndcK.ad tb.a a of thu ctt®tai ma be foca.nrd+d to tba
Dopy Y Dcponmao:t ofIn�+tric!Acci't.cs�'Offioe oflsur.oco for t6.
°Dv='se vai5c=xioo and to i s)rO`llls lock waioa 25A of MOL!51 as l=d to the=Pcmitioa of cimiMl pec-%lti=
comisag of.fiat orup to S 1 SOO.00 and/or im{xi of up w Doc Yu cnd ci iJ pmattia is BSc form or.Stop wort Ord---ad.
firer or:;100.00 a day Lp!ZXa mc-
i For �v+e only -
Pcrmit Numb- --
��A�—_ Lot
Si
gnaUn-c of te l E .
SECTION 8-CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9:'Reais ere` omeniproveineirtont a'a �_ O Not Applicable ❑
Company Name Registration um er
Address Expiration Date
r_
Telephone J 0 —�
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...... ❑
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
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SECTION,5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ''
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [Q Siding[0] Other[CIJ
Brief Description of Proposed f
Work: 05,o4,us 7Z, ✓`[//�ln
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa f Nexit krocise are' ar cl#pox% `o xis t hOuthi omp ete, w,
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 QR CONT.RACTOR APPLIES FOR BUILDING.PERMIT
//1 /4t�anLr7 as Owner of the subject
property
hereby authorize r-9
a n m behalf,i II relative to wor au hor' ed by this building permit application.
Sign re of Owner Date ILL
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.
Print Name
Signature of Owner/Agent Date
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Section 4. ZONING All Informati6h 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
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bIdg&paved
#of Parking Spaces
^
A. Has a Special Ponnit/Varunue/Rndi ever been issued for/on the site?
'
NO 0 DON7KNOW 0 YES 0 �
IF YES, date issued:,
IF YES: Was the permit recorded otthe Registry of Deeds?
NO �^��
� uum / mxvvv 0 ,"o
IF YES: enter Book Poge and/or Document#
B. Does the site contain a brook, body of water orwetlands? NO �_� DON7KNOVV «~� YES
IF YES, has permit been or need to ba obtained from the Conservation Commission?
'
Needs tmbeobta[nad »�� 0btaimed v�� Date
x�� \~�' ' �
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 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre oriod part cfo common plan
that will disturb over 1acre? YES NO ��K 3
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
_ d��' ` Deparlme>oituse�only � �,
a
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—13a ill I Department � r
_ 2`1 ain Street
m 100 a .
North mpt n; MA 01060
41 -124 Fax 413-587-1272 ° an �
F.
AP ti 9 tON TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1.-SITE.INFORMATION
Thls section t6 be'completed by office
1.1 Property Address:
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PIT_
Map mot Unit
Zone �:! Overlay District
Elm S7 Dtstnct ° .CBpis>�ict ,... _
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ame rint) Current Mailing Address:
- Telephone
Signature
2.2 Authorized Ag fit:
Name(Print) Current Mailing Address:
Signature Te phone
SECTION 3-'ESTIMATED CONSTRUCTION COSTS tG U U,
Item 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
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
i
Building<Commissioner/Inspector of Buildings Date
1
1182 BURTS PIT RD BP-2006-0190
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35- 195 CITY OF NORTHAMPTON
Lot:-001
Permit: BUiidinQ
Category: BUILDING PERMIT
Permit# BP-2006-0190
Project# IS-2006-0283
Est. Cost: $5000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Edward T Corbett 119488
Lot Size(sg.ft.): 11543.40 Owner: DIEMAND ROBERT W&DEBRA J
Zoning: SR Applicant: Edward T Corbett
AT. 1182 BURTS PIT RD
Applicant Address: Phone: Insurance:
1 TERRACE VIEW (413) 584-2546
EASTHAMPTONMA01027 ISSUED ON.8122105 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 Occupang Sienature:
FeeType• Date Paid: Amount:
Building 8/22/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo