36-182 ��ATO
Cl itp of Naztfulli halt z =�
� � �ASSACIt 1ib[tt8
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street ! Mmmicihal Building !'
�y time/
Northamp(oii, MA 01060
N
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction sul)": .-'ssor. Tlie state defines "liouleowner" 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 buildin,2 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, V1 WCC71J - V 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 (9 Pr-))03
Address of work
location
Qii'iil) tit
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OF
212 Main Street blunicipQ Bukdq� I'M
,",`Orthalnptonj Mass- Q1 0C)0
(IMPENSATLON INSURANCE A11PIDAvri,
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tl-ie coll"I v,��,o havc the fbkown wrlcVs conannymn vhvw--,:
(AMC of
(Name of Annamol
'Nai-inc Of Con"L!-,"C"ol
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not wcc on a MCC inn,M Audi Q a&Z"D"norn:51 w W1 on gwo
,_-.;)i a ya-3 0 _ r:'-- -,)/,C',((j L!_',2�1(5)) --a
legal"ZW4 Of=1=up hyt<Ut)Ct,tom Co;z;jxrrilion Act_
cov�Sc vc.-jfcztioG r.:-A ukr s::ic-ci:5A cfMC-!,152 cin 1,L'to tl>a pcv_�I::Cs
cowh1bg of I By of up to S 1000 Cc an vcs i-PinnM 0
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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
.n.� _ ��. r 's �za
9Reistere'd_Home Irriprovement Contractor �,, ��, _ Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
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...... ❑
=11� n �Me , wner E empt�on
The current exemption for"homeowners"was extended to include Owner-occupied Dwellin-,s of one(1) or two(2)farnilies
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 fe-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 d State of Massachusetts General Laws Annotated.
Homeowner Si nature •
g u v _ —
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing L
Or Doors ❑
Accessory Bldg ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: Pt V\. S c1ti_(T4 t 1<44!�4 VC"1� 1�/U
Alteration of existing bedroom -_-____Yes --__ No Adding new bedroom _-_ Yes — No
Attached Narrative ❑ Renovating unfinished basement _-__-._- Yes No
Plans Attached Roll C' Sheet L)
6a.'WNew hou'se atJd or-addition to existing housing complete the;,followin _
a. Use of building : One Family_ —_- ?v✓o Family ---- Other
Oti'er
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. _ Mascheck 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
L Septic Tank -_ City Sewer Private well City water Supply
SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
S as Owner of the subject propert\,
hereby authorize _ to a(,: or
my behalf, in all matters relative to work authorized by th �)uilding nerrnit anp!ication
Signature of Owner _ Date
_ .�_1A-IC V ++`4�`� _ 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
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF 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 bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO __ _ DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW _
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained _Obtained ._ Date Issued:
C. Do any signs exist on the property? YES L"
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES
No
IF YES, describe size, type and location: ____
City of Northampton Status of Permit
Building Department CUrb Cut/DrIVBWayXPerlllltri
m �� �
212 Main Street Sewer/SepticAv
� ailablitty � r
Room 100 Water/Well AvdjIabrllty � ,f
Northampton MA 01060 Two Sets�6f Str�ictural Plans r t
phone, 413 587 1240 Fax 413 587 7 P I I/Sit e Plans
-- Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
( SECTION 1 - SITE INFORMATION
— _-- This section to be completed by office
1.1 Prop-erty Address:
s = Map _ Lot Unit _
(D b Zone _ Overlay District
Elm St. District CB District—__—
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of_Record:
JbI
1
2.2_Authorized--Agent:
i
..rt
SECTION 3 _ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) tc Official Use Only
ccmpleted by
i-�errnit
-- --� -- -- --- -<-
�lJl dlilp 1115 00 (a' �i! i .!lhg Permit Fee ----
— t
- ----- - i Total Cost of
e Istructlon from 6Z
�. Pi11 mbinS
j Building Permit Fee
I I ,
4 Meclhanic rla,.•,^,.
5. Fire Prote ton � — -
6 Total = (I
1 q, ,eck NU[nber — --
This Section For Official Use Only-
Building Permit Number: _ Date Issued:_.___-_. _ — --
Signature: — -_--
Building Commissioner/Inspector of Buildings ate
1
g, BP-2003-1194
G1S#:,r COMMONWEALTH OF MASSACHUSETTS
� CITY OF NORTHAMPTON
J
art.,,; "=
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2003-1194
Project# IS-2003-1856
Est. Cost: $300.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: Homeowner as Contractor
Lot Size(sg. ft.): 15289.56 Owner: VASSALLO VINCENT P&KELLY J
Zoning: SR Applicant: VASSALLO VINCENT P & KELLY I
AT. 119 DUNPHY DR
Applicant Address: Phone: Insurance:
119 DUNPHY DR (413) 586-9740 O
FLORENCEMA01062 ISSUED ON.6123103 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF & INSTALL RIDGE VENT
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 Occupangy Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 6/23/03 0:00:00 1852 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo