25C-215 (3) M 'S�N1.
p4'Ttv+MP�O
of Nazthaillpturn
�7 855ACttIISCttS —
s
cwRt
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR
212 Main Street • Municipal Building a
Northampton,MA 01060
r
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<�r,: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 f _-
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 buil Ing department for the City ofNorthampton-wants-any person(s)-wh-o-seek-t-o -
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 r'.egulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfilll,
sonotube holes (before pour) a rouzh 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, 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
Dare
Address of work
location
4f �\Tcrfljulilpfoll -
A ' f ��c�ckr}Intrlla' ._
o DEPARTMEI-IT OP BUILDr-\'C INSPPCTJONS -
212 ?thin Strcet Nfuntupal DuIldin�
Northampton, Mass. 01060
WGRI�T_,IZ'S CONMENSA TIO.N MSURANCE 'FFM,'VI7
F Lv L�
(lie.--nsxlpermittcc) ------ - -- --- _.- -- —•-- ---
\Vitb a principal place of businessfresidence at: - --
i
(pone:!)
( t/ci ty/slalz/Zi p)
1
do hereby certify, under the pains and penalties of per7ury, hai
( ) I am an employer providing the following�%vorlrcrjs Cornocasau0 Cove-
.19c for illy
emplovccs worlong on iliis job:
i
(I-.gc an=Comr ml) (Police: Dzt`)
i
( ) I am a sole proprietor, general contractor or homeowner(ci:c;e one) and have hired
the contractors lined below cqbo have the `60o,,viop_ worker's coMoen_"aaon pokles:
I
i
(N=C 0', COn(^CiO'. (Iri-ur3nc-_ Coinpa i)-/ilobc (Hi :!)mwuon bate)
1 _
(Name of Connaor) (insurance Comoanl'/•POUM, Numb--_r) (Expp—"aon Daic)
(Name of Connamo;) Omsuiance Company/PoGc)- Numb:J) (–Expiraoo Daic)
(Name of Contractor) (I=11anC:.Comrzay/Policy NUMIxr) (Etpiiaiion Da1L)"
71amto incv.ic iaforxn�oo pc^isia:a to.11 ooa--- 3){ sole proprietor and have no one woridng for me.
1 ( ) I am,a home owner performing all the work myself.
1 NOTE:pl-,.bc wZrL LL M:.-.G rsx�loy pciom to do �- c—z oc c rc,nir-orx ca.d,, U-,-;or
aat MOM tb:�i5oe t=itr is u+si�the bomoou-na'rcmda or oc the was xb zpp�tbc-ro t-r ox C=2,—.Ry coed--oi to be
1 c=rploy_s un, -tb-..ui rt==pc--t'on Ac(GUI 52-=1(5)),=ppliaaoo by.bo, mo=rc c ti c a pcmit a_-7 c-ri6=� tL-
109pJ rua+c of a aploy.r uader d> Wor�de C,ompem.lioa Aoc_ .
i
[tusdcatnad dts x ooyy of thi,cacemma m..y be for--I-d to the Dcy.rtmcoa of In�.aviJ Ac do..Ii'Off o or l+ar•nm Jr-th.
covea.sc vciG-aioa cad tiu L-il=to+oauc lco%,x p-c=3&-,soctioa 25 A of MOL 152 cue led to the iz=p i oa of=imi=1 Qa1aWt
00=i:r�of a rMc orup to S 1,300M ar>d<or 6${r6o,=a orup to ooe yLr cad c,ii peaJtia io d.rom or.Stop Work Ord--ad a
ft=oC S 100.00 t d:y tpj=t�
i
l For dq. —� ony
- 7 Pcrntt ` lML--r
Lot� p°-
T
-
4S.itim of LicaaS=fpermiu= e
I
i r
SECTION 8-CONSTRUCTION SERVICES I
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9fite rs erec §rr"c ;"`itte `writ act Not Applicable ❑
Company Name �� Regist��on t�um r
Address — Expiration Date
C %! !� �� 2"l✓ Telephone
l
SECTION 10-`WORKERS'COMPENSATION INSURANCE-AFFIDAVIT(M:G:L,c.152,2§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 license,provided that the owner acts
as supervisor.CMR 780, Sixth Edition Section 1083.5.1.
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
r
SECTION 5-DESCRIPTIOR OF PROPOSED-WORK(check all applicable)
New House ❑ Addition ❑: Replacement Windows Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[O] Other[E:3]
Brief Description of Proposed '
Work:
Alteration of existing bedroom es No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
saw� N`ev�:�oifise ,�•� di `' c��ex�s�IliO�isinc "�ompl�tethe; o toai�c�±g:
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 BE COMPLETED WHEN
OWNERS•AGENT OR CONTRACTOR:APPLIES'FORBUIL-DINGPERMIT
as Owner of the subject
property
hereby authorize
to act on my behalf,in all matte relative to work authorized by this building permit application.
Signature of Owner IV Dat
as Owner/Authorized
Agent hereby clare 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.
.M1
Print Name
Sign ure of Owner/Agent Date
Section 4. ZONING All Informatibh 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 3
Frontage
Setbacks Front ! z
Side L:! 1 R:' 1 L: R: '
Rear
Building Height ' '
Bldg.Square Footage i % €� i
Open Space Footage % [;
(Lot area minus bldg&paved
parking),
#of Parking Spaces ---
Fill: s ?
(volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued:1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW t YES
IF YES: enter Book F I Page'E and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 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 I NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES NO 0
t ;
IF YES, describe size, type and location: }
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 ,- NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton '
Building Department
212 Main Street ,
Room 1,100
Northampton; MA 01060
phone 413-587-1240 Fax 413-587-1272.
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR REMO H A ONE OR TWO FAMILY DWELLING
_.
SECTION 1.-SITE INFORMATION
1.1 Property Address: *
Ttsseorttd be completed byoffice
t �
� PQ ^ �Llt �pFt,
Zonek Overla�i Distract
SECTION 2-PROPERTY'OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Nam4(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent: .J,
Name(P`' t) Current Mailing Address:
-L7 C17Y
Si urb Telephone
SECTION 3-ESTIMATED-'CONSTRUCTION,COSTS
Item • Estimated Cost(Dollars)to be Official Use Only
cprWleted bV permit applicant
1. Building (a)Building Permit Fee
2. Electrical 1 Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection Y
6. Total=(1 +2+3+4+5) Check Number
This'Section For.Official Use Only
Date
Building Permit Number; 1'ssued:
Signature: ,-
i
Building Comm issionedl nspector of Buildings Date
39 NORTH ST BP-2006-0755
G1S#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-215 CITY OF NORTHAMPTON
Lot:-001
Permit: Buildinq
Category: BUILDING PERMIT
Permit# BP-2006-0755
Project# JS-2006-1160
Est.Cost: $7000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: James Roberts 117154
Lot Size(sq. ft.): 22781.88 Owner: METCALFE BARBARA JO
Zoning:URC Applicant: James Roberts
AT. 39 NORTH ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTONMA01027 ISSUED ON:113012006 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 1/30/2006 0:00:00 $25.002846
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo