25C-100 e'
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DEPARTMENT OF BUILDDxTG INSPECTIONS
INSPECTOR '212 Main Street • Municiral Building
Nortliwnpton, MA 01060 5
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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 i:is/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 fami _
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 buildinz 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 DAY the project until such time as the proper permits and inspections are
made f
I f understand the above.
(Home ,ow er/ esidenvs signature r esting exemption)
I will call to s hedule all required buildin nspections necessary for the building permit
issued to me.
Dates
Address of ork
location
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DEPARTMEWT OP BUILDr?\'C INSPPCT'IOt.'S
212 Main Strcct A'funicipal Building
?Northampton, Mass. 01060
- woPd ; �
IZIs CONITENSATION LNSURCF AFFMr'iArl
(li ccusxlpertni ttcc)
with a principal place- of businessfresidence at:
(phone')
(s Ucity/SLUC1ap)
do hereby certify, under thc.p?_ins and penalties of perjury, hat
( ) I an an employer providing die follo%ving hvorkcr's comncnsadon coverage for my
erplovccs lvorlong on this job:
(Los=--nom Conr.-m-) (Pelicc:Nu-mgr) --- (r:-piratior, Dom)
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O I am a sole proprietor, general contractor or homeowner (c c:e one) 2nd have hired
the contractors U. ecd below wbo h.2ve the follo%viog -worker's ca�oen_taoon pclicies:
I
0"Ia me Oi conmici0r) (InRlrzn r. Company/?GUci ?�tL1IIl=<T) -`•?lid 0 l�IIC)
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(Name-of Contraor) (Lnsuanec C.omoan-v/pOUM, Nuncfr) (-ExD m6on Date)
(name of Conlraao;) (L suiane;. Compan}'/PoUcy Nzlmbzr) (Expirt7en Date-)
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(Namc of Contractor) (Lasuranc—c Compauy/Poicy Numbir) (Ex-p m6on Datc) .
(ntxx�-,667iocn.1 ddc�irnco,to induct_iafocm-ioc pc-U" to..0 waz-LOS)
> I am a sole proprietor and have no one working for me.
( )\ I am,a home owner performing all the work myself
jNOTE:pl=-=be cu-xm e,--w•t-.Je bcc mo=o ra w-bo c=plcy pcco=eo Lio c� tr• —e�oo C rgaII wOfX ov.d.•<(1_F of
ont mote theme tFsee=rr is the bomo,VC rimed.,or oo the}So•,inrti rppsrrt=a=tbceo c ax Vcz�r1ty oe=d to be
citployc-3 u--' the cc=p--*'oa Act(GLIl52-=I(5)�_pplinbon by a bomro -=fcr_lice.or pama r=y c ids tl:c
of en==Ployer under d,-W«f=e,Compomati, Ad
I undo-rraad zb-a aopy orthu car= may be f-----ded to the Dcq,rcmcact er]nS+rs;d Acod..I3'OM—cr 6=—for tbe
oovcabt vczif cnioe artd thetUtac to iu==tovcraCc under soctioa 23 A of l-tOL 152 c 3z ted to the imps m of cimia31 pcO3W=
ooazismg or a fine crtp to S I}00.00 andlor 6rcp ri of up to ooc)-=Lod ci i7 pmahio in t5c form Ora stop Work Ord--and a
Gm of Si00.0o r day aptinst tnc
Ford u.c only -
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Lot• l
Siva rr of Li ctatiucc 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
7 NotA Applicable ❑
.8�2ea�s"le �ombinarav�merr /o��itiac�to ��, � PP
Comp a am Registr tion u e
Address ry Expiration Mato
Telephone
SECTION 10-WORKERS'COMPENSATION'INSURANCE AAFFIDAVIT'(M:G:L.c.152,4 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...... ❑
NXI
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homeuwuei to engage an individual for hire who does not pnSCP-.s a license,provided that the 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-vear 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 a dersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
No mpton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
He owuer.51gAature
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check-all applicable)
New House [] Addition ❑; Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [EJ] Decks [p Siding[o] Other[p]
Brief Description of Propos AIAICC
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa �#�I�ew�� ous��no��;actcti#�on:#o+ex�s�nct�#iot�slnc>r'.��omylete�:the��oTlan�ti�ci:
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 7a-OWNER"AUTHORIZATION TO BECOMPLETED WHEN,
OWNERS AGENT°ORC;ONTRACTOR APPt_1ES`FOR BUJLUING:PERMIT
as Owner the subject
property
hereby authorize
to act on my behalf,!i� i matt rs relate to Work allfty6riffpd by this building permg application.
° G C
Signature of Owner Date
ter- declare that the st temen s l as Owner, thorized
Agent he e and information on the foregoing application are true and accurate, a best of m knowledge
and belief.
Signed under the pains and penalties of pedury.
Print Name
Signature of Owner/Agent Date
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Section 4. ZONING All Informat-i6h 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 j
Rear
Building Height
Bldg. Square Footage 7—
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume,&Location)
A. Has a Special Perm it/Vuhance/Fndi ever been issued for/on the site?
��^ ~�
�_� VV v~� � ^
N� ~_� DDN7KNO YES \_� -
IF YES, date issued:'
IF YES: Was the permit recorded ac the Registry ofDeeds?
NO �� D
�~� vm / umum/ 0 ruu
IF YES: enter Book Page' and/or Douument# /
' �-------�
B. Does the site contain a brook, body of water orwetlands? NO 0 DON7KNOVV 0 YES x~�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
-
Needs tobeabtaioed ��` 0btm�mad x�� Date
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x_� \_� '
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location:
D. A-r-e there any proposed changes to or additions of signs intended for the property? YES NO� v~�
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,n,filling)over 1 acre orisd part nfo common plan
that will disturb over 1acre? YES � � NO
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|F YES,then a Northampton Storm Water Management Permit from the DPW is required.
- -City of NorWampton
m
-Building p De artmenf
- 212 Main Street n _
Room 100
h ir�r!j Northampton; MA 01060
phone 413-5 7-1240 Fax 413-587-1272 a
_-.
,APPLICATION TO CONSTRUbT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1'-SITE INFORMATION
{ This section to be corflpleted bx offce'
1.1 Property Address: - f
Tone Overlay Di tnct
'+EImSfuD�stnct . �_'' KGB D�sfnct
SECTION 2 PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Addres
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Telep
Signature
2. uthorized A ent:
Name Current Mailing Ad Ness:
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 r
6. Total=0 +2+3+4+5) tjC, C, Check Number
THis Section For`Official!Use Only
Building Permit Number: pate
Issued:
Signature: !— --
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Building Commissioner/inspector of Buildings Date
49A GRANT AVE BP-2005-0882
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C- 100 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0882
Project# IS-2005-1216
Est. Cost: $2800.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THOMAS DWIGHT 100524
Lot Size(sq. ft.): 5662.80 Owner: ANUSIEWICZ EDWIN J&HELEN P
Zoning.URB Applicant: THOMAS DWIGHT
AT. 49A GRANT AVE
Applicant Address: Phone: Insurance:
27 MAPLE AVE (413) 584-2138
HADLEYMA01035-9710 ISSUED ON.3122105 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: Date Paid: Amount:
Building 3/22/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo