36-177 6
O�'S1iAMp�O
Gl ity of Xort4aiirpton z
�ASEACh1iElttE
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
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(.,, 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
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
(�zflt >�f it>-tl��tttt}�fc11t
55 A C11 Ilse I7
m DEPARTMENT 01' EUILDDl G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKLR'S COATTENSATTON INSURANCE ASFU)A TIT
i
;:,ith a principal place of busiress/rc: dcnce
lstrceUcit•;/ = :/j
do hereby cel�iNT lllla " III- 1) !]1S 2iid 1)Cil 1t1CS O1 )CrJllf-Y,
( ) I am an employer providing the fbllo%virlc V.vor'•_cr's corllncnsnon coves"c for my
elllplovecs wor-Erig on tlhis job: v
(Insuanc Coctpam) (Pc-c:Num,ber) (rte ir,:tion Date)
( ) I am a sole proprietor, .,entra l homeo l;l�mer (c
LT
cle one) and t--vc hired
the contractors listed belov -;,to ll� the :olio er s,' I ^i -5.
L:� ork s coL:.pen dor ;: .:c.c
(,N=c of Contmcto ns -�ncc nn.•
r) � Co: :...a„Pc!ic, ?�tu.tnbcr)
(Name of ConiIamor) -- (112-surz Ilc c (E .` ilon Datc)
(Name of Coancior) x-":r':i;0D, Dat,--)
- (Name of Contractor) — (lasut-anee (:0111. .:y!Policy Numb-r) Date)-
(.^,ILtG11.d'±I!]CY:11 S::Yt:{-••�,..�_•�•:;O :il.:'{:' ::::'K:]:r C;Ci:r-:::L::::::: nil O::J i:[•1
C 1 21111 it Ole plUpllCtC)r 2':ili1 htI'dC no OI1C 'r.'Or�iiit� t0",' inc.
( I hill <? IIOIlle C)AVI1Cr ii�iLC'I111I1�' II i_': iI 1�O(l.
HOTH.:plc�sc bc nwalc ti-at•.v ilc
not:Here than throo Uni+s ir,%,-I-c!i
--a-ploycs U.-Id-cr tha wr'c-"e,cc --._:im r-r (GT,152�--I(511•-,—._:tic:-.by a hertrnn-xr for e
Icgal rt2l—of an o=plo}•er under tLn Wcx kcl&Co,•t;,w=--.lion!.ct -
I undc^ct..nd thi a copy of 01,,ctatct-s_'r:iy bo fot-lx -J to tI' [Ytiartzrnt of Ir du.:jJ Ac6ei &Oi i of i:_.+.--a for U-
oovcr ge vaific zlioo and that fultue 25.&of MGL.152 Cw Icad to the iml siiiat+;e i.^1 P--U:c=
C ut ng of a fur_of up to S L. .00 a:t—"cy i^:itrivx Z of;;p to cr. }- �:.-S Civil,)C=1tic5 in d<fooll of t
f rm of S I OOAO a dry
- rcr c1q%utltrrtal u+c cavil}' i .
Pcrtnit Numlr:r -____ ---------___--`
�y�'
I S!,_, . cure of i.icc _cJl'crnl;:Ic: r.J, ' F
Now
S,EC30N 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
�Rei?s e e ome Yrro vem'entContracto , 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...... ❑
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 ocal Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
5ECTI0I 5 S. u P �OTI OFA-PROPOSEDPWORK chec{ )l a hcable �
.e,:a�
0".SO!
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Wor . &,c, a or l 5o oye 1 lzs. t'�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll D • Sheet D
a °fi e o a" i"d ona`dd;trop to exis ing hous�n�o ffl'1eflA§ft e fola.owrng:
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. 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 .
I. Septic Tank City Sewer Private well City water Supply
SECT (3t�7� INNER i�'HORIZATION -T0 BE COMPLETED WHEN` Im�OWNEaS ENT OICONTRACTOR APPLIES FOR BUILDING;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
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
Sign ur er ent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION r
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
i
Frontage
Setbacks Front
i
Side L: R: L: R:
Rear
Building Height
i
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 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT 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 NO
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:
Northampton
U
1 g Department
Street
R om 100
�KSPdlrha m ton, MA 01060
40 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
T This sechait to be compete boffice
1.1 PI'ODerty Address: � ��� �'�' �' sr �•r,�,. "� �'� �a�`���t ms
t
j) n//fir/ry-��1�/�^
I ✓/, r/ '1, I / / !` 1
SECTION-2,-PR OPERTY°OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Sig e
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION.COffS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building Building.Permit Few
/ `
2. Electrical (b):Estimated,Total Cost of
Constru ction 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 Offidial Use Onl
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
75 DUNPHY DR BP-2005-0196
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:36- 177 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-2005-0196
Project# JS-2005-0240
Est. Cost: $1074.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 15028.20 Owner: WHEELER LINDA J&ROBERT J
Zoning: SR Applicant: WHEELER LINDA J & ROBERT J
AT. 75 DUNPHY DR
Applicant Address: Phone: Insurance:
75 DUNPHY DR O 586-3853 Q
FLORENCEMA01062 ISSUED ON.8117104 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP TOP & SHINGLE OVER SIDES 1 LAYER
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 8/17/04 0:00:00 5155 $25.00
212 Main Street,Phone(413) 587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo
w
75 DUNPHY DR BP-2005-0196
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 177 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-2005-0196
Project# JS-2005-0240
Est.Cost: $1074.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: Homeowner as Contractor
Lot Size(sq. ft.): 15028.20 Owner: WHEELER LINDA J&ROBERT J
Zoning. SR Applicant: WHEELER LINDA J ROBERT J
AT: 75 DUNPHY DR
Applicant Address: Phone: Insurance:
75 DUNPHY DR O 586-3853 O
FLORENCEMA01062 ISSUED ON:8117104 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP TOP &SHINGLE OVER SIDES 1 LAYER
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: df(
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATI OF
ANY OF ITS RULES AND REGULATIONS
Certificate of Occupangy Occupancy si nature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 8/17/04 0:00:00 5155 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Conunissioner-Anthony Patillo
NNW