25C-053 (3) Y Y _
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DEPARTMENT OF BUILDINIG INSPECTIONS /
INSPECTOR `212 Main Street • Municipal Building '>o
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 iris/her construction super,;sor. T he state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be,a one or two-anu 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 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 fegulations. 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 occupanev
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.
Daze
Address of work
location
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„p `E 0�T 3 Of
� P _ E �Z asatcrh ntcll e' _
j w a DEPNtTI.4ENT OP 5UILDI,,'C INSPECTION'S
212 Alain Strcet Municipal Building
j Northampton, Mass. 01060
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WORICER'S COIATENSA-MN GNSURANCE Al=, i.V1-J'
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(Iicc s perm}flee)
\%9Lh a prulicipal place of buSlDess/reslder]ce at: ------- -
(phone-!)
do hereby certify, under the.pp-ins and penalties of perJury, _hzi
( ) I an an employer providing the followine «•orkcr's comocnsado, Cove--Sc Lor mN
employees wonting on diis job:
(IaaLran=Cornr.�r) (Pclic:Numbcr ) -- ( :pir`tior, Daz,c)
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O I am a sole proprnecor, general cootraccor or homeo e-aer (ci:cie one) and hive hired
the coat actors listed below who have the follow-inp- worker's comaep_,-adon policies=
(i+alll: Of C0 r Ci0") (1n51 x1111 COIAD1f1�/PGIICi ?�tuIll-<I) (fI':Jlr-3U0 I)MC)
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(Name of Cootraor) (lnsaranc;, ComoauviPOlimi `unc_r) (E%-Dirailon Dale)
(Name of Coaa-aco;) (Insurance Company/PoUcy Nambu) (ENpi—a600 Daic)
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(Name of Contractor) (Inslran Comeairy/PoLicy Numb`.r) (ENpitation Datr) .
(aQac:h�di�od rseC.ifni ---,to incur iaforni'ioa Pe'ta'l to.0
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( ) I am'a sore proprietor and have no one working for nee.
I am.-a home owner performing all the work myself.
jNOTE::ple`a_�be earut o—-LJc bcc e=O+ ,r ivho asPlay Peso to da M —rreo Cr rc,�air•••otic oa i d.•e1L�of
Got @OCC t1L'a t-'—t^. -to ti.b] the bomoa-acl made or oc Lb,pmuob Z�pty(L.cp-`11 11YC'CD LT DO(C^J.:Dy oc.=-d--cd to be
—)Pl-y—-01—the pct(GLl S2-=l(S)).appU=600 by a homcow=fcr:6c=x«permn cr;y c 461 =tl c
1c9A n».,of oa cznloy«coder dro Wockc t Coa>Pematio-a Act
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. I undcsza.pd t>ta a Dopy oC lhi.m1®�m.y tx for-,.carded to tb,DcQnnmcoi of IndiatiiJ Am Offoo of l-r+r+ooa for tha
novc>.Se vcrT'atioa and Uu L-iltac to write teovervZc tmdrs soetioa 23A of MOL 112 cnn Ied to the=pastioa cdcrim nA Pic
ooaxiwit$of a fine of tP t051300-00 an&cOc iaz{aiypam of uP to Doc yc:r ead cMd pm+hin in 6e form of a Sksp W crk Order zd a
fim 0(:M0.00 i d_y apia:a tnc
Fa dcpvlm=-'�u,c Doty -
Permit Number -
- t'ot
SigaaLiin of ,
Lic=zccJPcm tee e .J
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SECTION 8-CONSTRUCTION SERVICES r
81 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
NE �a�
gages"EeTeomedrn .owemersCan#iacto° - Not Applicable ❑
Company Name
Registration—Num er - - _-
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION'INSURANCE AFFIDAVIT(M,GtL.c.1`52,§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 buildine 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.
AIso 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.
/H omeowner Signatures/mil
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)''
New House ❑ Addition ❑:. Replacement Windows Alteration(s) Q Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[0] Other[d]
ief Descripti n of Proposed
Work: G-P,414 ';eaO F
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
ga 1f I�Cew fi0USea.nc or a'_&a�oWexhAidd( b,§Jna'=cornplet #he.follQ�nrrncar:
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 Ta-OWNER AUTHORIZATION-;TO`BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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
1 ,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. 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
Frontage1
Setbacks Front —�
Side L: 1 R:L L:+ R:I
i--, -
Rear
Building Height
Bldg. Square Footage % ---
t
Open Space Footage
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill: r
1;
(volume&Location) I
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW Q YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book Page;' and/or Document#`s
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 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 0 NO f
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO Q
IF YES, describe size, type and location:
1
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 n r NO 0
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IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Norti a mpton
Building Department
212 Main Street
Room 100
a +ice
Northampton; MA 01060 '
phone 413-587-1240 Fax 413-587-1272 Ito ,
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
1 Property Address: Th►s serf+on to be completed by office,
,+ �J �;
+
x
NO('
x _
x
EIrn Sf_D�strixt' _ CBp�strict ` .
SECTION"2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(�P/rriintt))-� Current Mailing Address:
of r►G '/ / ����� /�� `7L�' yC 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
comp feted by ermit applicant
I'll. Building (a)Building Permit Fee
70
2. Electrical (bj Estimated Total,Cost of
Construction from 6
3. Plumbing il Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number p �
This Section For Official Use Only_
Building Permit Number, Tate
�' Issued:
Signature: r
i
Building Commissioner/Inspector of Buildings Date
or it
51 LINCOLN AVE BP-2005-0383
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-053 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-2005-0383
Project# JS-2005-0511
Est.Cost: $600.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq_ft.): 10062.36 Owner: MCKEEVER JAMES E&PATRICIA F
Zoning:URB Applicant: MCKEEVER JAMES E & PATRICIA F
AT: 51 LINCOLN AVE
Applicant Address: Phone: - Insurance:
51 LINCOLN AVE O 586-4825 O
NORTHAMPTONMA01060 ISSUED ON.10/4/04 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 Occupancy Signature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 10/4/04 0:00:00 398 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo