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DEPARTMENT OF BUILDINIG 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 i:is/her construction sup<:-., sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a d e or two fai
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 r',egulations. 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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ATO t..
of �\Tc illailiplo 1
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cJ DEPARTMEI-IT OP BUILDr,G INSPECTION'S
212 Main Strcct Municipal Building
iNorthampton, Mass. 010GO
WORKER'S COi\TENSA'nON LNSURA-NCI✓ AI FM,,'�,Vj-j-j
(li=s.=JpermJttc,-)
vIrl h a principal place of businessfresidence at:
S� �rYYCUC K s( 1— r `� M c_^!r!S`, (l hone') SSG 7 71
(sa�t/ci rY/sZatda p)
do hereby ccrd. -, under dic.pi'-ins and penalties of pegury:, hat
( ) I am an employer providing the following Iworkcr'S colnDUIS-EJO, covcrvgc for 11)),
etuplovccs Nvoriong on this job:
(L2nu-.�n=Come) (Polio:Nu-ter) — (r:pimion Dam)
i -
( ) I am a sole proprietor, geoeral contractor or hotneow-Der (ci cie one) and Lave hired
the coacactors Listed below who have the following workers comDenssaDon pokles:
_
0113m: of conmlao0 ) (Instranc,: Cotnoanyti'ouc; (-ExpiiJu011111c)
(Name of Councior) (lnssrzncz Comoanyt'PoUm, Numcrr) Dwc)
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(blame of Connmclo.) (IIISWac= Compan y/policy N,.unbu) (Expui z600 Datc)
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(Nz-Mc of Contractor) (Insurance Comcaay/Policy Numb r) (Expiration Date).
(.11a[b ddtroeal bee,tfao�.�-to atdud iaformaaoc pest:�Lo B coat-lLam)
I
O rietor and have no one worl�ng for me-
I am a sole prop
j ( ) I am.a home owner performing all the work myself.
NOTE:plese be zwwt t4.,.-.]o bo=,=,mCn N o c=picy pctom to cio -*•-,• mr .=joa r tgau work as.d%-J:-.;of
ace mots th a tksu—,I in Wbch the homoow oc r=d._a or ca the p-alndt zppunear1 tber_o r.-r ooc Caa _lty oe=.d.-rcd to he
eitploye uz)d. the w= rt:oc=P-_.,:m Aa(GUI 52-=1(5)),:.ppli=6m by.bommave fr c Ge. .�a pewit ra:y e.idmec the
legil nano of ea¢71oyx under d.w.,ku er comvom..Liou Act
I
t uodcr:.aa tha a oopy of tt 6=a—t o y be f---ded to tb<Dop.�of,.A.r;d A.6d ndY o(Gioo of ttaul+.00n for tbo
cove a&- veila3i00,ud th_i L-..iltae to s=im bow aCe uadc section 25A of MOL 152 eaa 1�to the i�sivoo of mminA pcai(tio
cOOMLvi t of.fine orup to S 1300.00■ndtot ixr o xi orup to ooe y=e.od avi]pm.Itia io tSc form of.Slop Wort;Ord-.ad
r>m of S 1 00.00.day.ptiatt me
For.-ty,_ �.t u,c only
i } Pcs wit
Numb-
Lot
S i mawrr of Lic=zcc/Pc m-i u= e
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SECTION,8-CONSTRUCTION SERVICES .+
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
�Jtea steoimproyreenCortra o - Not Applicable D
n
Company Name Registration Num er - — -
Address Expirfition Date
Telephone- G�37/9—
SECTION 10 WORKERS'COMPENSATION 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...... ❑
b E.
if
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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-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
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401
SECTION 5-DESCRIPTION OF-PROPOSED WORK(check all applicable)
New House ❑ Addition ❑:; ReplacemerftWindows [Alteration(s) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[o] Other[c:j
Brief Description of Proposed
Work: � LLB f ��
l/i/�7i!- i�lJt+t-c�LL' j 1- �
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
a. ',fitm-a' "' ;.. h. ,. "�. "s.�* ".sr r�y,".:,a*' _ S,^
sa. ev� ose anidadcl `iantex>ISing Tiorasingwcompfete ttae-7Qtlourmg:
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'AUTHORIZi4TION,-,TO'BE COMPLETED;WHEN
OWNERS AGENT OR CONTRACTOR APPLIES.FOR BUIL"DINGPERMIT
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
'T- as Owned) uthorizedj
0!&d hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my kno3(edge
and belief.
Signed under the pains and 'penalties of perjury.
Print Name
Signature of Owne gent '�' Date
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Section 4. ZONING All Informatioh 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
Frontage
Setbacks Front , 1---
I
Side L 1 R: i L= R:I
Rear I a
Building Height -- r-
Bldg. Square Footage ( %
Open Space Footage
(Lot area minus bldg&paved i =7 �a i
-kin
7-;
#of Parking Spaces i
Fill:
volume'&Location)
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A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page; and/or Document#s
B. Does the site contain a brook, body of water or wetlands? NO 0 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: f
C. Do any signs exist on the property? YES 0 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
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 U
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IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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----- City of Nortf ampton �
Building Department
212 Main Street
l � Room 100
Qno, c0(`'S Northlampton; MA 01060
phone 413-58 1240 Fax 413-587-1272
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APt I ICATI.ONf6 CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION'f-SITE INFORMATION
Thts section to be completed byoffice `
1.1 Property Address:
°Nlap 1.cst ��°� Unit<
ZoneOverlay Disfrtct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Address:
Telephone
Signature
2.2 Authorized Agent:
J c h'ki r E.1 i f S-6 )!m eve /L ! L r' r S p!'94
Name(Print) Current Mailing Address:
S' ' re Telephone
ECTiON 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 Total Cost of
Construction-from 6
3. Plumbing Building;Permit fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) /6 7, Check Number
This"Section For Official`Use Only
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';!Date ,
Building Permit Number Issued:
Signature:
i
Building Commissioner/Inspector of Buildings Date
BP-2005-1021
CIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2005-1021
Project# 3S-2005-1402
Est. Cost: $4167.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Corbett 104000
Lot Size(sa.ft.): 19645.56 Owner: HINKS STEVEN L&MARY LEBEAU
Zoning URA Applicant: John Corbett
AT: 35 STRAWBERRY HILL
Applicant Address: Phone: Insurance:
56 Dimock St (413) 586-8712
LEEDSMA01053 ISSUED ON:4122105 0.00:00
TO PERFORM THE FOLLOWING WORK:INSTALL VINYL 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 Occupancy Sienature:
FeeType: Date Paid: Amount:
Building 4/22/05 0:00:00 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo