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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 780CMR 108.3.4 to
act as has/her construction super-,'isor. 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 these inspections can result in failure to obtain a certificate of occupancy
result in failure to obtain a certificate of occupancy
until the work can be 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.
Date
Address of work
location
C1-zfyj of �ariljamptolt
DEPARTMEhrr OF vi1ILDR) G INSPECTIONS
212 Alain Street ' Municipal Building
Northampton, Mass. 01060
WORICER'S COMTENSAT'ION INSURANCE A. t Agri-'I'
(Iiccnsc:J�crinutcc) _- ---
%vlth a principal place. of busiress/res Ccuc t:
6114'lDClclS_(
do hereby CCrt11}', ulnA ;1- L11c it 1S i'.iid pGil i l• .. Oi pc.:Tjllf " ilm!:
am an eRlpioyei pro"'Idin- the iollo"vir. - '.':Ort;CrrS COII9pCI)SHUOI] GO�'CIa�C 'Or Illy
emplovices working on t?Lis job:
(IarlranG Compam') cue,N y ifxr) ----- (Expi Tti7o Datc)
j I al_i7 a sole prepnetor, 2encral con -ac`or klci clp- Oct) and l:a'.e iLired
the contractors listed beiow ;,ho 1:�.' the ollC'.'vii:y ti'�OI KPrs C'0m-0ensz-t on o! cics:
R'lame of Contractor) (Ins�r ncc Come. a�:Pc1ie� NurnL r) (Exp:rat;cr: Datcl
(Name of Contractor) (11IS�:;nee Co r_.`/Pe!ie' N=,b--r',
D2e i
)
(Name of ConLmctoi) (lIIa� 3I1CC CO I] :1i]:i/ Ol.�j 1 lUIlf}.I) X;.'.;C O hate)
(Dame of Contractor) —- (Ins rand Com;,ay.y/?olicr
(.^.:t-lGl`-.dr�liJ CY:11 S_K�t::..r.��-•+-.�•.�:�-::!'�::-...:.Y::'.a::C('.��:_' - ..li C� .
� -# IITl <i so1C 1)I Ul) 1CCJi ii.ld hL l— no
1iI1 ? 1:OI71C OAVIIC. tiCi C`[??1 ( ,r;
Ii
NO'IT. Icaae Lc awarc:}•a -wL;' o ct_p ;>. c n;i>:�c cr:-;air
I . ; �c k,c<;,c:n�zr_ra�+�. yam: •+ - _.
not uxrc th n ihtoo uri+s i.^,t 1 dt Fx f L ;.iz. r^: a a;' :•::: zot•_rtct_r1 LhCr o c�c>_�Ecxral}y
c11ptoyc3 u sri',cr t}r
legal rtatus of an a=ployx under tLc wc'kc'g on;o r.tion -ct V
II
I undc-' twd di-Lt a copy of Ilia ciatc:s_•cuy bo fay'ucS J to ti,D-j—toun of IndislriJ A"j6�&C foo of l:--74 for tlx
covaase'rermc:t1ioa and that L•ilurc to e,ti.:re coy rM u d r caic^25A of MGL,152 can lead to tlx impasition o;r ^n l petal;:rs
000si.zty g of a floc-of up to 51-SMOG mnt for i-.:nri:rz c:_of up to rr. }- r:.1 evil ncnz}t a in de fix7n cf+S!c:';vc Y Ch tad
r:tom acsloo.oc)a day���.it,-t m..
�� Fcr =uutt'�es1 UK a:ty
5r natureofi.ic�:7 cJI' .rmi;tc.;___ _ r
SECTjON 8 xC ONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
Reg�ste re me rtto"owerrib on Fg.-f6jr,
9 .- Not Applicable Cl
Cyr x� �cw i ye�rL� /Q ycGy
Company Name Registration Number
-6 �r)"0().C Si 71,,(0 j�6
Address Expo Date
s. G C, J Telephone S In 7i 1
SECTION lO WORKERS',COMPENSA,TION INSURANCE.AFFIDAVIT(M,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 acecptable 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 fcr 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
� aix, �
SEGTIONH =�D S"-: PT�ON�OF PROPOSED WORK check all a hcable
An
New House ❑ Addition ❑ Replacemgn Windows--[Alteration(s) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: �A s, VIV-1 L r-e-0 W cfA--cam-avi uJL4"e-T
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll❑- Sheet 0
ba i le o sexy id or a clltionrto ezi-sting housaingg�comple. eithe foU10Wing:
a. Use of building : One Family l 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. Mascheck 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 0�1 ItiER"�gUTHORIZAT10N TO,BE COMPLETED WHEN
OWNERS,XGENTRQ CONTRACTOR APPLIES FOR BUILDING:PERMIT
I, 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/ uthorized Agent
hereby declare that the statements and information on the foregoing application are true and accurate, to the ees oi—m�-~J
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
l:
Signature of Own r/ n . Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning "t
This column to be filled in by
Building Department
Lot Size
f
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
i
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW
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 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property?YES_
No
IF YES, describe size, type and location:
C
ijr of NorthamptonNF
' uWing Department
1$ Main Street
Vk pR
Room 100
Northampton, MA 01060
p1ioiie'?ii-587- 40 Fax 413-587-1272 � w
, .
1-a4PPCICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Properly Address: Tf>tsecho�x to'be completed by office
* zee,
3
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
LA r" Cc-y
Name(Print) Current Mailing Addres sL,_.,
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Si re Telephone
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)'Buitding 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 =(1 +2 +3 +4 +5) /�S �'• Check Number
This Section For'Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
17 HIGHLAND AVE BP-2004-0883
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C- 194 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-2004-0883
Project# 35-2004-1318
Est.Cost: $1852.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sq_ft.): 5749.92 Owner: GRYGORCEWICZ WALTER&SOPHIE&
Zoning:URC Applicant: John Corbett
AT. 17 HIGHLAND AVE
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:3117104 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL REPLACEMENT WINDOWS
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 Occupangy Sienature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 3/17/04 0:00:00 1840 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo