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GFity of Wart4ain lyton
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DEPARTMENT OF BUILDI?tG INSPECTIONS
'212 Main Street • Municipal Building
INSPECTOR 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 his/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 oiie or twig fanu 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 Wi1 Ing department for ttte City Of Northampton-wants-any persons)-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 eegulations. 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 3 O�D(6v
location
� _• E � ��a7aRrFl atrtle' _ •�_
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o DEPARTMENT OP I3UILDf\,C INSPPCTioh'S
i
212 Main Street Municip.ai Duddin�
j Northampton, A1nss. 01060
1 «'O RICER'S C O INO ENS A'IT N i;I S UP.AN C E A FI'M A VIT
(li ccvsxJprrmitttx)
��zth a principal placz of businessfresidence all - - -
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15
i (st��t/d rJ/natcfa p)
do hereby certifj, under the pains and penalties of perjury, ha)
j ( ) I am an employer providing the folio%vin «orkCr 5 cotnocnsaoon coven^e For Iny
employees working on this job:
I ()--SUx-' .) (PoLc. .Numb-_r) D?_Le)
( ) I am a sole proprietor, general contractor or homeowner(cii cie or_e) and have hired
the cooiTactgrs lisle ► below wbo hzve the following workel's cac:. pen_CaDion pokies:
i
j ONamc of Con[MCior) (Inssumncc Cornea t)•/2�o6c Datc)
I — —
(N2MC of Contrctor) (La,-Wanec C.omoan-vipolier NI>.tnc_f) (Dgor=tion Date)
(Name of Conrraao;) Ozstuanc-- C.ompany/Pouc)• N:unh_r) (F_xpirtion Datc)
(Name of Contractor) (Iasuraac--Compazy/Policy Numb:() (Expiration Dalc).
(.-nh nd3tcot i rScv,ifa� _-ti•w e�e!u�iaf_•-;o;peta,ia:as to.11 eoe-e..co-�) - -- __-
i
a sole-proprietor and have no one working for me.
( ) I am..a home owner performing all the work myself.
NOTE:picse be eta-Art tti... L�]e lxoxo�vcra�bo c=ptey pc-om in Lb o ^e c--zcjoa cr repair•, ric on of
not Mors lb-L'—--rd in Ich;cy the bomoo+wc raid=or cc the pvu»,j,xpppa • thc-ro�i aoc C=am .Dy ac:.zd.-ni to be
ci:pioyc�unGc the �-�on Alt(GU I5I=1(5)).=p pii--%E by n bomcowD fc c ti c a pcmri cry c.-id LY
leS2j CL=a of as ey-t,loyx under dbO Wor{cda Coospam J;Cla Act
t uadc-L d li A a ooyy of thii-I—(]Say Ue&c-vrda to the AcradarY C ffLG-or Laur+000 for tb.
�`^�o"t"��L3110a rJd tlLi r:.ilta•c to smut tovcrad^c tra„SG souioa 2511 of I.toL!52 as icy to the i�irio�or c-:,n:n.l pcasl7ia
ooa:LSStg or a fiat of tv to s 1 SOO.00 ardor of up to oa y-_r eai evil peaJ•,ia is tx room or.SLOP work Ord=aad
rum ofsloo.00&d:y
For 6�artm�t u,c«,ry
Permit NuIDbCS
_Wz-&6 - hczp° Lot Si J
Lure of Li ermiuee _
SECTION 8-CONSTRUCTION SERVICES -71
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:_ /;'�" 066"'366
License Number
Address Expiration Date
Signature Telephone
9tea` eXetlam ci€c mentit.arrt a+Cto own / Not Applicable ❑
d3--n-�-
Co Pant/ ame Registration um er -
Address Expirati6ffDate
/iV6 ^7Jr'J�� < d�� Telephone
SECTION 10-WORKERS'COMPENSATION INSURAN"CE' FIDAVIT(M.G L.i%152,4-25CIM)
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...... ❑
a
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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-near 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
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SECTION 5-DESCRIPTION OF!PROPOSED WORK(check all applicable)
New House ❑ Addition F--],, Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [tom] Decks [p Siding[0] Other[E7
Brief Description of P pos d
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
"�,^ �" -fit _u
VE W-� buswn:- c e iil iot�stc><cr.camafe the o fai t:
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-OWNERAUTHORIZATION TOBE COMPLETED WHEN
OWNERS-AG/ENT°OR CONTRACTOR i4PPL1ES,1=0R BUILDtNGPERMIT
I, f ,�G1 vw"" as Owner of the subject
property 11 1
hereby authorize �1 /'�l'�� �������t' �U✓1-7� C�y�
to act on my behalf,in all matters relative to work authorized by this building permit application.
ignature of OwOr Date
as Owner/Authorized
gent ereby declare that the stateolents and information on the foregoing application are true and accurate,to the best of my knowledge
bnd-belief.
Signed under the pains and penalties of perjury.
11
Print Name
/ X b
Signature of Owne Age Date
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Section 4. ZONING All Informatibil Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
This colimm to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg.Square Footage 011'0
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume*Location)
'
A. Has Special Perm ever been �suedfor/on the sheY
' � x�� �~� �
NO � � D�7K�W �� YES ��
IF YES, datmissue&
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 OON1KNOW 'ES
IF YES: enter Book Page' and/or Document#
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B. Does the site contain u brook, body of water orwetlands? NO *���� DONTKNOVV �~� YES �~�
IF YES, has permit been or need to be obtained from the Conservation Commission?
-
Needs tobmobtained v���~� Obtained �x~�`� Qaum |ssua�'
' �
C. Do any signs exist on the property �� ��� YES �~� NO v_�
^
IF YES, describe size, type and 10nutioM
D. Are there any proposed changes to or additions of signs intended for the property? YES NO »~�
IF YES, describe size, type and location:
E Will the construction activity disturb or filling)over 1acre or isdpart ofocommon plan
thaw0disturbovnr1unre? YEGK~_�$ NO K~_.�
/
/F YES,then a Northampton Storm Water Management Permit from the DPW is required.
mpton
�pf Northa '
B'4qng Department '
X12 Main Street
•' Q
Rom 100
Notk%amptbn; MA 01060 1 1240 Fax Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION.1 -SITE INFORMATION
1.1 Property Address: Tials section toe c1eted b�raf#ice
D d 66)
s
SEC1ION.'2-PROPERTY OWNERSHIP-/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Pri Current Mailing Address:
Telephone F—°
Signature
2.2 Authorized Agent:
P w 77C
Name(Print) Current Mailing Address: (,, jl r
c'e
� T
�ff 0 ``
Signature Tele ne
SECTION 3'-'ESTIMATED`CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building -Zoo <(a),BuildingPermit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6'
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection '
6. Total=(1 +2+3+4+5) Check-Number
s Section For Official Use Onl
Building Permit Number -Date
Issued:
Signature: ,-
i
Building Commissionedlnspector of Buildings Date
' 63 GPLKWIi BP-2006-1064
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -00
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-1064
Project# JS-2006-1572
Est. Cost: $2007.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin: DE Sheppard Roofing 105885
Lot Size(sg. ft.): 8886.24 Owner: EDMUNDS ROBERT L&GEORGIA P
Zoning:URB Applicant: DE Sheppard Roofing
AT. 63 GRANT AVE
Applicant Address: Phone: Insurance:
224 BERKSHIRE TRAIL (413) 587-0092 O
CUMMINGTONMA01026 ISSUED ON:41712006 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE GARAGE 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 si nature:
FeeTyue• Date Paid: Amount:
Building 4/7/2006 0:00:00 $25.00852
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo