17A-299 (4) O�'CHA111p�0
g.� ti$ Crz y of Nart4amptan
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m DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building ,y
Northarnpton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as his/her construction supc;r,•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 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 roper 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
location
of
� 6 fi?csexrfJnsrtte '
m UEPfiRTMENT 01- BUILDING INSPECTIONS
212 Alain Street ' Municipal Building y j-
Northampton, Mass. 01060
WORKER'S COMPENSATION I SURANCE A < < AVI.T
1,
(liens^:�rc;tn;uc^)
NvIth a principal place of busiress/r dcnce t:
do het-cby CCI-`df1 ;, u?lclCl" d7C p-,ills and 1)C:il 211t 1C 0 7C: III I -
aim all employer providirlg the rollo'willi '.':0('r;CrS CoInpcnsS,Lion cove:-a�C Tor Irly
enlployces wo6drig on dies job:
(Lnsiranc� Company) (P c; Ntum,be r) ---- (Ea::r.:aon Datc)
j I anm a sole proprietor, gentral c'r homcawoer (circle one) and :la',e hirer_'
the contractors be:ovzi vto tht `O!l: v oFke S C-010' -r Orl
(Name of Contactor) (Lnru~ncc Cann. :,, Poliel Nu�ntcr) (T Date)
(Name of Conn.ctor) _ (7�ISar,_ncc Con _:w/Pe!ic,' i�[t rIl(Y r) (l :p .ado Date)
(lti'ame of Contractor) (Ins nee Co .;ii olio, Nuultr r) ( z. r,:Iior, Date)
- ( ee oc — (Ins Ianc Cerny V.Y,'Policr Ntlm�_r) (I zpi aio Date)
i
( 1 Lull a Sole prUl)rICCC1i i:=l'1 have no JnC ..'Ors iii{ tot tile.
I dill �l 1:0I1?C O�VI1C: i)Cir'.)'R?II?� a1 i_': V:....; i `s;21f
NO"I-F,.:please tc nlva:c tt!st.t ilc tx uo«zr s .o c p!c;Irz:-_ n:: �_'r�nc�co r. m or:--air
not u ccc th❑tlztoo uui�i tvf
oil he f;:�v.t:r r :c 3 f a;L •_:.�z _r cr�r1 hcao t c n t(;crxrzlI,
—ploycs wn,cr t}x twci x s cc r•�::i n,rr.(G',1,152---!(f)',,-pp'aticn by a 6omco«?,cr:`or e l ccu cc
leg,l n�tz,c of an anployx under tt:o WcvYcr.Con.; -motion!.ct
I undc--xt nd tha!a copy of ai:x ctatc:c:cuy bo fo w+vci J to tl»IY.txi tzrn of Icx uatrial Mil,�:f oifico of for tlx i
coves-asc vcriiirlioc and th_t&Aurc ul---; cti.iM 25A of MGt,152 can Icad to tlx imposiliat c;c ^i.�I pccsl:u
comizting of a ftrr-of up to S 1,500.00 a:ti,or of lip to cn-} enj civil i r=Ities in tt.c Fools of a s!cp
f c-of S 100.DO c diy cg%in_.t ta:. .
Fu �vzrrssl u.c cf,ly
Ji nature t�f i.icr n:c:JPcrnnitc.:
S 13,10N 8=;CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: -f-- Not Applicable ❑
Name of License Holder : rf bVbt G1 d 0/ d0 /
License Number
/
Address Expiration Date
Signature Telephone
Re a:e ome m r=:semen ontractor- -
_ 1 S Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone SIP
SECTION 10'VIIORKERS' CONtPEN,SATION INSURANCE.AFFIDAVIT(M G:L.-e. 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 acccptable 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
;SECTION 5-06 SGRIPMMI N OF PROPOSED,4W0RK check all=a I�cable '
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing .
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: r s 1 roar r e t11A i,,c- o t rS
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll ❑ . Sheet o
s6WWe-"-1h6—US-0 nd o a: dit�on to ezistin iousin`g comp°fie he follow�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. 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
SECTfQ : ate, WNERAU }IORIZATION TO BE COMPLETED WHEN
OWNEkSiq E ORCONTRACTOFt APPLIES FOR BUILDING PER
as Owner of the subject property
hereby authorizer to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
as Owner .AuthorAg
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
i
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 >C 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:
` of Northampton
' il`ding Department Y
212 Main Street
O04 - Boom 100
Northampton, MA 01060 ¢
phone 413-587- 240 Fax 413-587-1272
u -
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
�- ��_ �; Thissect�o�r to be completed by office
1.1 Property Addre55:
t _p� b
7 i�l "4 app.,za`}y
l -:m ^S -�:one3 Ih►erlay D�stnct
$�r EIm t���cE� .,LBflISIfl7Ct .c..0
SECTION 2.-PROPERTY OWNERSHIP/AUTHORIZED`AGENT
2.1 Owner of Record:
V rev a t- cl &J d i 01 13n fV4--
N nt) Current Mailing Address:
l
Telephone
Signature L
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?ermit.Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (I + 2 +3+4+5) a Chock Number
This Section'For-Official Use Ohl`
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
Y `
157 HILLCREST DR BP-2004-0938
GIs#: COMMONWEALTH OF MASSACHUSETTS
MM:Block: 17A-299 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-2004-0938
Project# JS-2004-1389
Est. Cost: $4500.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: TOM WEST BUILDERS 101418
Lot Size(sq. ft.): 22128.48 Owner: WILLIAMS BREVARD SPRINGS JR
Zoning:URA Applicant: TOM WEST BUILDERS
AT. 157 HILLCREST DR
Applicant Address: Phone: Insurance:
164 SOUTH MAPLE ST (413) 586-1812
HADLEYMA01035 ISSUED ON:3131104 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: Receipt No: Date Paid: Check No: Amount:
Building 3/31/04 0:00:00 4653 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo