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DEPARTMENT OF BUILDING INSPECG'TIONS
INSPECTOR 212 Main Street • Municipal Building '
North,-unpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as l: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 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
/I, � �-�� understand the above.
(Home ow/her/reside is signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 5' aCIO 6
Address of work
location
-
F{o �o�`E �I��7 L7f ��CTI"fl�illll�JfD11
o DEPARTMEI T OP BUILDr)\10 INSPEC iol,S
212 Main Strect Municipal Building
Northampton, Mass. 01060
i
i
WOR CCR'S CONQ')✓NSA-MN MSURANCE Al,
i (li ccnsccJpermi ttcc)
with a plz,'IcIpal place of business/residence at:
_ (phone')
J (so Uci ty/slab:/ i P)
do hereby certify, under the pains and penalties of pc 'ul-y; =.h:t
i
( ) I am an employer providing the follo.ving %vorker's comocns-nbo, cove-fie for Iny
etuployces wortorlg on tills job:
i
z (Iamn-ancc Comn=v) (folic: Nt=b�ccr) -- ' (T=,-piratior, Du) "
I am a sole proprietor, general contractor or er ( c;e one) and have hired
the contractors listed below who have the following po!icies:
49 r1 C�: - -: .
(Name of Coomnor) (lnsuranc;, ComDaIl-,-/Polk- Nu t-:0 (Ekvirtion Date)
i
(Name of Contraeior) (Insurance. CompaDy[PoUq- Number) (Expiraoo Date)
(Name of Contractor) (Insurance Comrany/PoEcy Numb-r) (Expir-diioa Day).
(and,addit:ocab chcct,if nccc -,v to pcstaiains to.1]
{ ) I am a sole proprietor and have no one wor-idDg for me-
(-A I am.a home owner performing all the work myself:
i
NOTE:plea be aware a-�-1 Jc bcaco.�ocnµ-bo employ pcsons n d7 •%*-+—= c=-,=: oc c rcpao worX on a d%-U-1-C of
aot mocs a a Lb roe=rx in-Sch the bomoowvcr raid=or oa the Crouccs xpp r _r1 t them e-r ox C=�_Zy oc,=.d=-ci 10 be
ca*()--s—'—the--kc{z -�c=ioa Act(GLI52-=1(5)3 ppliaboo by a bomco-oa fcr:h=r-.or permit n=y tb:c
IcVJ n_^•,or as e=zployx under d,o WA e,Compmvtioo Act
I uo6-nz d tha a Dopy of thin ct ..=m.y bo for-xurdod tc the Dopartmrat of In6cui.J OM-or I+ra+r`°°°Jr-t6°
oov=-XLe va-ireaioa and thrl L-.iltut to soauc'covcznse under%oction 2 3 A of MOL 152 as I...d to the imposi -of-i-i p-a -
0003ira of.fine of up to s 1 Soo.00 andior ix of up to ooe yar emd a%it pcmx-tjo in tx form of.Stop Work Ortia and a
fl=of SIOO.Do a day aplaA me
' For dcp.ru:'=-a1 u,c Doty
Pc'riIIlt 1`t tlIIltX7 .-.-
✓// 1.dap." LOt K .
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Signariue of Lia� rm
scclPciucc -
SECTION 8-CONSTRUCTION°SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9<',,WJisteia Nomerlrripro emen Goi t a foc x P yyJ ,; Not Applicable ❑
Nffi+sw .+FA'£ �S6hYi ^KT.S,,.k.xh: 5Aw1s-U ,s #,GiS:.or.
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL.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...... ❑
11 . H rn � per geWE -
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 \J
1l
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all armlicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ —Siding[lam] Other[0)
of D i lion o Pr pose 1
"Work'-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa if New �i' t1§64M46F a dMHOrwtc.e stlncr=hou 11 r»r e e a i of ovrrma:
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, floodpiain 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'-O.VYNER'AUTHORIZATION-TO BE COMPLETED-WHEN
OWNERS AGENT OR'CONTRACTOR APPLIES:f,OR:BIIfLDING PERMIT'
I, 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.
Signature of Owner Date
I, as OwnedAuthorized
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 Tm ,�
Signature of Owner/Ag t 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.I
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 0 DONT KNOW 0 YES 0
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book Page and/or Document#'
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained Date Issued: s
C. Do any signs exist on the property? YES Q 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:
x
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 0 NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272 I� �r
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1--SITE INFORMATION
This sect►orti to b- Ieted bX office
1.1 Property Address: K
3 +f r
a
�Z'one Overfay Dtstnct
�Elcn"�S�D�str�zt -` CB:Dtstrict, .
SECTION2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name Fri J� Current Mailing Address:
/ /,q —X�� Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3 :ESTIMATED CONSTRUCTION COSTS=
Item Estimated Cost(Dollars)to be Official Use Only
completed b ermit applicant
Building 6000- 00 (a)Building F4nnft: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
Building Permit Number. : Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
r
DR BP-2006-1185
GIS#: COMMONWEALTH OF MASSACHUSETTS
6I4 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-1185
Project# JS-2006-1748
Est. Cost: $6000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 13982.76 Owner: KIMBALL SHIRLEY A&DEANNE R
Zoning URA Applicant• KIMBALL SHIRLEY A & DEANNE R
AT. 47 FOREST GLEN DR
Applicant Address: Phone: Insurance:
47 FOREST GLEN DR
FLORENCEMA01062 ISSUED ON.5/5/2006 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP, PLY & SHINGLE ROOF & REMOVE
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 5/5/2006 0:00:00 $25.007589
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo