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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 78OCNM 1083.4 to
act as iris/her construction super,- 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 occupancv
until the work can be inspected. I
-
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
R��yeu r i� �z
_ �, nr tt�aiil�tocc - _ _
t B B 3;csinrflrtscf(a'
! DEPARTMEI-IT OP DUILDfNC INSPCCrIOFJS
212 Alain Strcet ' Municipal Building
! Northampton, Mass. 010G0
ry
«r0R14:IZ'S C01YIPENSATzION LNSURANCE AFFMAVI-l'
(lice-asxJpcm,)ttee)
' «n dl a pruicipal place of business/residencc at:
G-a d, rx Lkv)i
(phone') U67'-C
(SOT_-Uci ty/state/a p)
do hereby certify, under thc.palns and penalties of pc 'ufy.,- that
un an employes providing tfte following tivorl:cr's comocasat;on covcra for Iny
employees woriong on tliis job:
1 --
(Znsur-mac Conr�cy) (Pclic:Nu.�r) (r;pir00 Due)
am a sole proprietor, general contractor or homeowner (c c;e one) and Lave hired
i
the contra(ngrs listed below rqbo hive the following worker's cocpensadon parties:
(i+nlIIC O. CO"^CiOr) (InRralTC COITipa i)'/i�GUci NUM-1-c-)
(Name of COntraor) (Incessant:. Comoan)•/Po6c \`resew) Date)
(Name of Cones-actor) (Lasu=cc. Compao)•/PoUq- Number) (ESpir aeo Datc)
r
(frame of Contractor) (Iasuran Compa�y/Policy Numbcr) (Expintion Datr).
(aauCb �'oc�l bcC.ifncocs,«•to atc?u�iafoct�A�oO pertaiaias to A11 ec�-_ec:z)
{ ) I am a sole proprietor and have no one working for me.
( ) I am.a home owner performing all the work myself.
'.. NOTE:piece be evrxrc lfi,•kt.Je bemco.�vcra v.'bp�(Qy P�--'z w �--•;•- =-zcj o r rc;av�Qrk on.d..ctt_F,of
ant most chr a t� i'�is u'ac�the bomcm�vc reside o,oa the zpputte�r�tbetn :r ooc C.�:zny oersid rcd to be
c=ploycs undo the kui dz m Act(GLI52.E l(5)�zpptyanoa by A bov=o_=rr_lice__oc paZait rzy--d—tl:c
Icgal naaac of Aa'=P"yx`Oder dre Works a Coo • a Aa-
1 uOdc-= ad rbA a copy of tbi,c=-c r w=Ay bo f«-_ded b tba pop.Anmcod crL dvsncl A_d.=Y offices or 4 OOe ror th.
covcrxj c va•if c=ioo And ULr r_iltae tO saeurc'eovcr�under ioMioo 25A of l.(OL 152 c lid to the i"pes—of cimiwl peniltica
oomiaiag of a fine orup to s 1,�oo.00 xrzior orup to ooe ycr end civil pm.Jtia in BSc roc"ores stop Work orda And A
rim of 5100.00 A d_y tp!3 1 mr
Fx u-o"11
7 / Permit Number
Lot
/ ll
zr of Li�scc/perrstiucc e )
e
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder:— \�.�l l `, —S. �QI Al 1 r Y�—� L.50(0`1 LA Q
6 License Number
Address ) ~� Expiration Doe
1112 r x/C, L+L a 3
Signature Telephone
9--A, fiswerm mfrilnFdiieirienCoiitFacto - F Not Applicable .❑
ompanv Name Registration Number
Address Expiir taion Date
-11 Telephones
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT-(NI.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 Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTION 5-DESCRIPTION OF-PROPOSED WORK check ail.applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[0] Other[O]
Brief Description of Proposed
Work: '�^ t'! t—dW 1 10 �,(G'�4)11-,Ct Sh: rl) ;h c (�. r C'� Vi eic( �� J
ti
Alteration of existing bedroom Yes No Adding new bedroom Yes No `L it
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet `
6a�[f IVe��rere�s�°arid-��-ac��it`rata���ls��ng�:�tae�sr�c�,�ro�p�efe:f�°�`� Cforrrt�rf�cl: �
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->OVUNERtAUTHORIZATI04-TO BE EOMPLETMD WHEN
OWNERSTAGENT OR GONTRAC OFtAPPLIES',F.OR=BUILDING PERMIT
I, G� C l /` • as Goat 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
I,
as Own /ge ereby declare that the statements and information on the foregoing application are true and accurate,to the best o e
an belief.
Signed under the pains and penalties of perjury.
C 1*4 (LU
Print Name
Signature 'Owner/Agent Date
, .
'
Section 4. ZONING All Information 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
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location) jl
A. Has a Special Perm it/Variance/Fi ndi ever been issued for/on the site?
�� ��
NO �~��� DON7KNOVV �~� YES ^��
IF YES, date issue&
IF YES: Was the permit recorded at the Registry o[Deeds? '
��
NO �� DON7KNOVV 0 YES
IF YES: enter Bonk Page and/or Document#�
'
B. Does the site contain a brook, body of water orwetlands? NO 0 DDN7KNOV 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtainmd �~� Qbta�n�� �~� Date Is :
�~� �~� ' . .
C. Do any signs exist on the pnoporty �� ��� 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
IF YES, describe size, type and location:
E. Will the construction activity disturb .grading,excavation,or filling)over 1 acre ovis it part 4o common plan
that will disturb over 1 acre? YES ��� ) NO ���)
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
i
City of Northampton Status oe�t � � �
Building Department
212 Main Street Sewexx�e tti Iabilt€ ,� k r �
Room 100 tilkae� IAyea6t� � �
Northampton, MA 01060 T All t� �t�rt�
s
phone 413-587-1240 Fax 413-587-1272 ?ofskteans
affierSPecr _ „
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: _ This`secttorx to be complete by ofrce
Map Lot Unit
Ck
E1 w, L Distrrct C�Qist[rct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT,°- - —
2.1 Owner of Record:
i6 2
Name(Pri t) Current Mailing Address:
Telephone
Signature
-
2.2 Authorized Agent: _
Na a(Prinv Current Mailing Addr s
Signature Alephone
SECTIO(NA-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=0 +2+3+4+5) Check Number
This-Section:For Official Use Only
-Date -
Building Permif'Number, Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
- f
:..
BP-2007-1029
GIs#: COMMONWEALTH OF MASSACHUSETTS
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-2007-1029
Project# JS-2007-001663
Est. Cost:
Fee: $0.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Cyrus Newman 142807
Lot Size(sq. ft.): 442569.60 Owner: NORTHAMPTON RECREATION DEPT
Zoning:URA Applicant: Cyrus Newman
AT. BRIDGE ST - SHELDON FIELD
Applicant Address: Phone: Insurance:
697 Bridge Road (413) 586-1093 Workers
Compensation
NORTHAMPTON MAO 1060 ISSUED ON:51112007 0:00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE DUGOUT ROOFS OVER 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: Date Paid: Amount:
Building 5/1/2007 0:00:00 $0.000
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo