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DEPARTMENT OF BUILDING INSPECTIONS
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INSPECTOR 212 Main Street • Municipal Building S ,
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supc,- =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 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.
Date
Address of work
location
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DEPIU2T.4ENT OI' BUILDING INSPECTIONS
212 Train Street ' Municipal Duilciing
iNrorthamptoll, Mass. 01060
NVORICER'S COMTENI SATION INSURANCE ASMAVI.T
1,
v."ith a principal place of busir,ess/re:i�enc t.
SiTC UCi t; :rj
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CIO 11creb} Certli�', L'I1a ! t lc p%il-1S ;Ind pGil ti7CS of pc:I�111�', i11A::
I am an CIIlpioye.r pmviding file 011O`.vil?L '. OI"r=C1 S CompCIISOL1oI1 GOYC;t: C pr my
Cinployces wor�dng un LlJs)Ob:
(Las,= CotaYan}) ^car;N -mbcr) h,pir,:inn D2IC)
( j I aa7 a sole proprietor, general C-mtrac`or ' r homeowoe: (cLcle one) Pnd 't:a`.,e hired
t.h`, Contractors listed belov+ i`1 0 Ii (�1 t0i1 .Pr �Oi ttQ�S GJr J°IlS°_ Oil 'O!i .CS:
(1`amc of ConL`:Ictor) (?RS`il ,'1C CCI^,�-::ii-PGlle; T�USTl�i) (Ex:r r-,•Ion Datc)-
(Namc of COL't?2C C)r% -- (71LS�:�IlG CG11 D_;1v�0�ICt' tiliIIl)f f) (I.`=Dir i7GII Dale)
(Name of CoatZ2CtOr - -
) (lli�;Ii"'„I1C.^. (-.;�iiJ "'D:i/i�Q�:C. 1`il1.II1�'i_I) - -�,-_= 3inn 1%1I•l)
- (Name of Contrilctor) — jas-uranct COIrr�.-y!Polic,' Nluml;Lr) (I:;: i.:tie-Date)
(^tLiGt:.GSjs�a[:al ti:cd....-'-.. :�..:_......- ....�r:..c_��. r- ._.... � r.ii.�:<.__.--...•�
i
t j I t1I11 <. gale propriet�)i <:I:;i have no one `..�;1-';.il;�; ion aye..
NO'IT:pfc ac be atv�c itst.l•ilc h v-co«rrs.:rs ct �1 ;r— n;t n cr u t;r d.c1i
not:Mete th n tfuce uui+s in iv! et he I:r.1�;,tr,�T=- c,t`,
r ploycs uti cr t}sr aver:rts c aticn ,r(GI.1>2.=m:(5)1,n ._a:ie;!ry s hIm,-ox-.cr`cr e liecu a
legal rtatus of=c ployx under tt:o Wcricrc o2,o riiion?.cL
I undcstand the i a copy of tbi, itatc:s•cagy bo fo x nrcio j tot; I of Tnd izriJ/u�il�t�C SCr of for Ut
covr7agc vmft=ioo and that Iailitrc to s-z:r;m�rM ur3: c�.ic 25A of MG1,152 can lc:d to ti
Comistiing of a fur_ofup to S 1-3CU.CO a:e.'Jcr of u,to or,-- er j civil'p-r Itia in dt 1i—n of S!r. ' 'r Y'-C}� n:d
Lri oCSIQC.QO a city
i of ki uvnntal u.c o fly
" t1171U'.:T I
— - I
Si nature
of i.ice l:cJPr..rnrittcc- __r_;- E
SECTION 8 G( NSRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
ERs er me mPro�ernentContracto Not Applicable ❑
ltl;(�►G� 64-1 wi CKi�vr�
Company Name Registration Number
�0 ?fKl/
Address Expiration Date
W ltyt Telephone
SECTION 10 WOR}�E}R5' COMPENSATION INSURANCE:AFFIDAV:IT(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 acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the buildine 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 fe.-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" certi es 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 �inJ
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�SECT�.gl�1, ;`1=5� P��Oi�li?FPR PO'SEDsWORK chectC��t a lacab�le � fi�
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing .
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ) Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: ►' AipiAbj, PCJi , Over' 04,Jhha&df' lh
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll 0-Sheet 0
a a " "difeon to existin i1 ing c0 M,Ae e Q how n��.
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. bimensions
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 .
1. Septic Tank City Sewer Private well City water Supply
SEC �O V R C� I.i.0RIZAT10N 70 BE COMPLETED WHEN
DWNEf �NC PERMIT
I, as Owner of the subject property
hereby authorize to acs on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, as Owner/Authorized Agent
hereby declare 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.
Print Name
Signature of Owner/Agent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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:
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City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587.1240 Fax 413-587.1272 t
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1!-SITE INFORMATION
1.1 Property Address: This sec to: o b. ., omp edgbyofif�ce 4
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�+ 3� �'•� �- f� Map� � �. ���_.
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�Zon � Qverla Distr -
Elmi'�tDistrict T >. CBDrsrtcfx'
SECTION W2 - PROPERTY OWNERSHIP,LAUTHORIZED-AGENT
2.1 Owner of Record.
M r'ChG t/ /--y (� re �uv � 7 �'2�y /M U13Y/
Name(Print) Current Mailing Address:
tl!3 -36 y - lots
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
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 TotalCost of
Construction.frorn_6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) S
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check number Q
This Section:For Official Use.Onl _
Bui{ding'Permit Number.,: -z00 -
TIssued.
Signature: Upo
Building,Commissionerllnspecto of Buildings - Date
BP-2004-0276
GIs'#: COMMONWEALTH OF MASSACHUSETTS
M T CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0276
Project# JS-2004-0404
Est. Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 6272.64 Owner: KOWCENUK-PRIOR CAREN A
Zoning. URC Applicant. MICHAEL FORREST
AT. 38 WALNUT ST
Applicant Address: Phone: Insurance:
PO BOX 37 (413) 369-8045 O
CONWAYMA01341 ISSUED ON.
TO PERFORM THE FOLLOWING WORK:STRIP AND RE-SHINGLE, INSTALL 30 YEAR
SHINGLE WITH RIDGEVENT
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 SiLynature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 9/11/03 0:00:00 MO $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo