36-164 (3) o4gtlAM p�O
� � �Gtassacltuseifs '=
of Northanyton
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DEPARTMENT OF BUILDITIG INSPECTIONS
INSPECTOR
'212 Main Street • Municipal Building -any 5 '�l
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sup<:•-,•'ssor. 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 -'
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 r',egulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfin -
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 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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P J 8 1nchnsclla' - -
a DEPnRTMEIJT OP BUILDf>\C INSPECTio?"s
212 Main Strcct Municipal Building
?Northampton, Mass. 01000
WOMCERIS COIATENSATTON AD=,
O1 CCIISxfpC7127JIICC) ....._-._.---
\ it i a principal place of business residence at: -- - -
1es/ /j 9f; �4�-����'� ®�' %� � `' � S'O�' I � U hone:') ��- X7`4 7
do hereby certify, under die.pa_ins and penalties of penury, :hat
an employer providing o he iollowin-alworkci's comocnsaoo;: coven^c for ut
)
emplovecs wortong on tilis job:
OmsZr-an=Conr,:_cy) (PoLicr Nu zbcr) -- (r,pirz orr D2j--)
O I am a sole proprietor, general contractor or homeowner(ci cie ogle) and Lave hired
the cootraciors listed below who hive the folio%ving workers policies:
01;a lc Of Con!^cior) (In urancc. Comp3,'1)•/P oUc ?emu nLC) (rti)Irjuon Datc)
(Namc of Contractor) (lnsarancc Comoaay/PoUm— Numcrr) (x-Diration Date)
(Name of Coaaaclo;) Glance Compacy/Pobq- Nasbj) (Expim6oa Daic)
(Name of Contractor) (Losuranc-- Comcauy/PoLicy Numbs) (ExTiratioa DaLc).
(aa1Ch:.d,4cocal '=.x�a.if acct-i.�•w incuct iaforMASOa P=-U iag to.0 cccr1n:3) -
{ } I am'a sole Proprietor and bane no one woridog for me.
( ) I ain.a home owner perfon=g all the work myself.
NOTE:pl==be cw-2rc o-u1 ]o 6emeuwvcn uto caxplay pczo=to c�a cis -• s a oo a rgiu work oa.d-x :-.g of
GO(moct d=twee tmrj is«vich the bomoowne rxsdo oc ca the poua zppurtcoss tS eo e c oot C-_xr.Uy oo=d=i to be
enployc-s---' the--k=--ee p_ tica qr-(GUI 52�1(S)),rppliation by a bomooava for lice_cc permit r=y evidco=the
1`5!ni'ue of ea==Ployar under 113 Wwkie,Compomatioa sloe_
I uadesiaod tha a Dopy of(bier mtcmcm m..y tx fo.-«asd.d to cb<pepanmOOx of Ina+astia Acodcat�l7rLoo of taav+oon for t>m
c0vcrIS-—irc3Iioc and th t L iltzt to so�uc tovcraac under socZion 23A of 1 tOL 132 m led w tLc i osirioa oleimias!pea kic
eomtria of a ftae oCuP to s 1300.00 and/or 6mPriioamcw orup to ooe ycr Lod aril pmahia is BSc room of a Stop Work Order cod a
fun of S 100.00 z day ap n:a mC.
. ,. For u,c«rly
Map: Lot
SiL;naturc of Lic=iscc/PcMIiUc� e --
SECTION 8-CONSTRUCTION SERVICES a
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Numbed
l
Address , Expiration Date
nom . J/
Signature Telephone i 1F r'
1
9tecistereFTomfrripeerien0ontacta Not Applicable ❑
`� ,fir, u%.c^i� ,ra► � y�,c.,�Xt C.�.
Company Name Registration um er ----
Address/ ,�/ a Expiration Date
/ /OF- err %% -� 0°%' Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVfT(M:G:L.c:
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 buil ' g permit.
Signed Affidavit Attached Yes....... No...... ❑
A-1 OX
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 rime,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°aaglicabie)
New House ❑ Addition ❑. Replacement Windows [AlWratlon(s) ❑ Roofing
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [0 Siding[ Other[O]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
s`ti..,. ;e�r�- '�' '"��'y ? �"l.:s "`°'": .s "P.` 'fit." .`-'......, f°? ��.r �, +�:•_* �
saf Nevtaase »dctdiznaxls#it_ a stncr eor>�iiztefe .o C"aurnca:
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
L Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. ftoodplain 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-'TORE COMPLETED-WHEN
;OWNERS AGENT"OR CONTRACTOR APALIES:FOR'BUlLDING•PERMlT
L Z as Owner of the subject
property j
hereby authorize el_�/'
to act on my behalf,in all m tters r lative to work authorized by his building permit application.
Signature of Owner Date
!, L� .+ }f f /�: f'r%A, ✓:1 ',_ as- Wei/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.
l t�J�"'Ur l I / /✓ r, -4
Print Name
Signature•eha mer/Agent > Date
Section 4. ZONING All Informatioh 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 — I—�
Side L.' ! R:! L:! R: F
Rear F
Building Height ---- —z r --
i
Bldg.Square Footage �i o"o
Open Space Footage % t � g--
(Lot area minus bldg&paved �i
parking)
#of Parking Spaces
Fill:
(volume,&Location) `
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:1 I
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW Q YES 0
IF YES: enter Book 1 Page; and/or Document#'i I
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:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: �_ N
D. Are there any proposed changes to or additions of signs intended for the property . YES 0 NO Q
IF YES, describe size, type and location: j —---
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 O , NO O
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r ... r--•--�-- (� �"' It ori:f•,iampton
i Department
12 ain Street Sevrt e
a
a m 1.00 e
c° ' 3 20Irttl p n; MA 01060 e
phone 413-5 7-12 0 Fax 413-587-1272 I?taSIe
-ar nr pill!pr C, ►�c�fGTl^�V thetpec � �'
APPL i "84 4 UCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1,-SIT_ INFOR MATT[ON'
1.1 Property Address 7Fus section to be completed byoffrce
Q ? d ��v? J S % 1 Map
�= ) �:' �`� /' �2 Zane Ovec(ay Distrrct
;Elrt Sf.Distract -: C�Disf�lct --- •
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT,
2.1 Owner of Record:
I'Rc` 'j-`' ' "'�
Name(Print) Current Mailin Address:_ R All
�r 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 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) T,> �i Check Number
This Section For Official Use Only
Date
Building Permit'Number Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
1070 BURTS PIT RD BP-2005-0286
GIs#: COMMONWEALTH OF MASSACHUSETTS
MW:Wgqk,:36- 164 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0286
Project# IS-2005-0372
Est. Cost: $5368.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group. B & R Siding 100465
Lot Size(sq.ft.): 12022.56 Owner: BUSHEY MICHAEL J&LOLA I
Zoning: SR/WP Applicant: B & R Siding
AT. 1070 BURTS PIT RD
Applicant Address: Phone: Insurance:
781 Bridge Rd (413) 586-4167 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:919104 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL 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• Receipt No: Date Paid: Check No: Amount:
Building 9/9/04 0:00:00 19505 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo