25C-065 ¢'SHAa1P�.
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_Criitp of Wart4ampton 1z
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DEPARTMENT OF BUILDD,,TG INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building
Nortli,unpton,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 c: , 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 fanni - -
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 ftulations. 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, �V Ox N 1A AV) ti e n 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 no
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Q DEPARTMEI-T OP DUILDI7-,'C INSPECTrOf.'S
j 212 Train Street Municipals Building
Northampton, Mass, 01060
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WORIC ER'S COIVII'I✓NS�TION LNSLrRAT�CE :�I I�� VI�
«rlth a principal place of business residence at: -- -
do hereby cerafj, under dic.pai-m and penalties of pcgwy, h.l
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( ) I am an employer providing tite following''%vorkcr's comocnsZboP cove zgc 'or in)
emptovees NvorUng on this job:
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(Ianir-an Comp ) (P4Lic: Nu r) (T',-pim or, Dam) '
O I am a sole proprietor, geaeral contractor or homeowner(c cie one) aid have hired
the coatractor-S listed below who have the follow' 2 worker's caooen_ta�on policies:
((+IlII1C Of CO r CiO") (lllslranc Cornpan)-iliOUC'i ,Ium_<r)
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(Name of Cootraor) R saua-nc;. Compa.avi?oum, \umc^r) (-Ex-Dir.:tion Date)
(Name of C00=10r) (Lnstu-anc Compan}-/Pol;c}- Nambu) (Eapirtian Date)
(N2-Mc of Contractor) (Lasuranc-- Comrauy/PoUcy Numly:r) (Expiration Daic).
if n�cei,_-}-w arc.' iarbrco-ioo Pete;+. to a ooa7_c.o�)
{ ) I am a sole proprietor and have no one woridng for me.
I am.a home o-,vuer performing all the work myself.
NOTE:pletc be warc tfi,• at ]aL6emeo.�vc 3 vtio=Play P�=-Law to d.3 �sr��r rc;aa work oa a d,-cJl_;,of
Oat Mc"LL-M l:r--l"3fa rII taaydt Fb.0 ui+cL�ots++ua r,.7d-,Or O�tb,(�-pU�,�y).gPuj-(rr+•*+,j p LT tXX(,".,.-kT-tt- OCCT:(S?Cd to tK
ciiployc3 uaCc the Nei cr,r� P=Lar-c.A=(GOI 5 L=1(3)x,_ppUca.6 a try a bomeoave fore tip--or pesma r=y ca id=cc Lb:
I-pl na1,c of ea cployx uadcr tiro Wortco(a Coa*—=ate Act
_ (undcyad tha a ooyy or thin mt--t my 1 e for-xurd.ed to tba p�garcm,m¢of i...&..-W A.ed.XY OCG—oI-
4aunooa foe th.
covenSc^airalio°°'d that U=to scauc bovmtse under 1,0 ioa 23A of h(GL 132 c=tmd to the ial�oa of—itsl pcaskic
0003 of a fine orup to S 1340.00 andloe i=�a of up W ooe ye=-r sad atilt pen.Pjc3 in be form of a Stop Word Orde and a
Gm
0(S 100-00 a d--y spj,Sj
ry For dcyutria.-al u.c orsty ---°.---
` Permit Ntunixs
Lot
t p�.a Lary o t�scclpc crni tics �1=e - -- -)
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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
9,R&gT!s ter-&, orri4 friiciEa�rerriec °Conti acf `R `s Not Applicable ❑
Company Name Registration Num er —-
Address Expiration Date
Telephone
SECTION 10 WORKERS'COMPENSATION INSURANCE'AFEIDA1fiT(M:GL.-¢.152,;.§25C(&))
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 Lcense,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 fd Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all:applicablel
New House [] Addition ❑:.. Replacement Windows Alteration(s) ❑ Roofing
Or Doors E3
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[[3] Other[E3]
Brief Description of Proqose F n 1 c\22� h � tv ,v C k. vice evt y5
Work: One Or-l'CV'► Aco0 A C CA , o 6�
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
NeW grou Mia sIf c&'hd l4 core ' eN 616W1iia:
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. 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 7a-OWNER AUTHORIZATION TO;,BE COMPETED WHENk
OWNERS AGENT:OR CONTRACTOR APPLIES FOR Bf11CDING:PERMIT-
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 hereb eclare 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.
9 OYAA
Print N nn _
Signatur wnerlAgent Date
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Section 4. ZONING All Informati6h Must Be Completed. Permit Can Be Denied Due To Incomplete Information
4�-� W'V 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
#of Parking Spaces
(volume,&Location)
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A. Hu's � o| Permit/Variance/Finding everbeen issued for/on thesde?
NO K DON'T KNOW 0 YES 0
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IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO K J OON1 Rmoxx 0 'E»
IF YES: enter Book Pag and/or Document#:
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B. Does the site contain a brook, body of water urwetlands? NO 0 DON KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
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Needs to be obtained x~� Obtaimed �~� Ommm Issued:
«�� «_� . .
C. Do any signs exist un 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 0 NO 0
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IF YES, describe size, type and location:
E. Will the construction activity disturb excavation,or filling)over 1 acre orisd part ofo common plan
that will disturb over 1 acre? YES K ) r NO K )
IF YES,then o Northampton Storm Water Management Permit from the DPW is required.
—•- q9 of Nortpampton
ilding Department
r— 1 012 Main Street r
I Room 100 rat r T
JUN — 2005 NiS pton; MA 01060 e M ti
phone 4 -58 -1240 Fax 413-587-1272fcxtt ata
cc $ 0ftt8t pectT � � x `
A1a�LlCATfA�A1 n r c ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address:
� Thls sectron to be cam�Ieted�by office
Y �Zo�e 4verfa�Dtstnct.
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Elm Sf aist�rct -_�` � � CB,Distnct ,::y
SECTION.2-PROPERTY OWNERSHIP/AUTHORIZED AGENT.
2.1 Owner of Record:
I�wv►9
Name(Pnlit) Current Mailing Address:
Telephone
Signat
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 /�`� 6 U (a)Building Permit Fee
2. Electrical /y (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee,
4. Mechanical(HVAC)
e
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Sectildr-rforOfficiall Use Only
wr Oate _ .
Building Permit Number. _ ""Issued:
Signature: _r
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Building Commissioner/Inspector of Buildings-- Date
280 BRIDGE ST BP-2005-1187
GIS#: COMMONWEALTH OF MASSACHUSETTS
MayBlock:25C-065 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1187
Project# IS-2005-1607
Est.Cost: $0.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa. ft.): 10715.76 Owner: CHEN KUNG-HUAN
Zoning:URB Applicant: CHEN KUNG-HUAN
AT. 280 BRIDGE ST
Applicant Address: Phone: Insurance:
282 BRIDGE ST (411) 585-8149 O
NORTHAMPTON MAO 1060 ISSUED ON:617105 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE PORCH ROOF & FLASHING
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 6/7/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo