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DEPARTMENT OF BUILDD�,TG INSPECTIONS /
INSPECTOR '2'12 Main Street • Municipal Building '
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNM 108.3.4 to
act as has/her construction sups:,f sor. Tlie state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two pa
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 fegulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfia
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
understand the above.
(Home ner/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
r
i
Ffio �c ot`ti �If�7 pf AT(j :fI�i3111ptOlI -
9 J f gt43SAcflns((ta'
Q DEPARTI.TE?,T OP BUIL-Dr>\)c INSPEC71011S -
212 Alain Strcct Municipal Building
Northampton, Mass. O1OGO
WOMCR'S COBITENSATION MSU Z, hCF AFFIDAVIT
(Ii ccusxJperml tttx)
%I-IIth a principal place of business/residence at:
— (phoney')
(sa-�tic�rrlstaLCla p)
do hereby cerLi -, under die pai IS and penalties of pcgur-, :hat
( ) I am an employer providing the following I'vorkcr's comocnsado, cove-ge for im
etuployees Nvorong on this job:
(Lnsu_r-an=Cor-ram') (Policy Nt:.cr) -- (r:-pira6or,Da[`)
O I am a sole proprietor, general contractor or h meow,-Der Lc;e one) and have hired
the coon acngrs listed below who hzve the follo�vl�or z>'s camoen_saaon pa!icies:
(Nam-, Of CO:,=c[or) (In2ranc;: Cornoan}vPobc; }gtuII1hG) l?a[c)
_ (N me of Contreor) (lrssrancc Ccmoaa`JP01ci Nu.mcr"r) (%aPL-M6on Date)
(Name of Connaao,) (Iusur-dacc Company[Pol;q- Nasb�r) (Expim6aa Datc)
(Na-me of Contractor) Gmsuranc-- Compauy/Policy Numbcr) (Expi-,ioo Datc)-
(nrIlGjl -,d6--:CCU iicC,tr ncoo.a--N to G]Gili�•iafbnnR =cc pClU�to att COD✓--=o:. )
{ ) I am a Sole proprietor and have no one woridng for me.
( ) I am..a home owner perfon=g all the work myself
NOTE:plc=be awzm t5,,. +{ to hcmr vcri..tio cxplay pc-L<=w ctD =—,zc:jaa c rcpau work on a d. U---`of
tux tnoce rhea ` _tait"La wbch the bcmoownc r=dc cc oa the Vv o,:!3�7p�,tbet �v ooe Cor_[ty oee:dcrOd to he
eirployes uc?—the—k=:�r�r ..'�A,=(GL!t 57 a t(5)�zpptiabDo by a bomco-na fer c lice:.or permit rr_y�-idmcc the
Icgl rt„+..or as cr,toyx uaeer tho Wortror'r Co�amat;oe AcL
[—4 -Ma-ad that a copy of thin mtcc>cm may tw roc' ,j d to tb<pcputmma of Indaatlid .—dcu'offioa of Lu-roc*for tbn
cove-a�c vrif ctioa and the L-iltac to segue kov=,y undo Io oa 23A of MGL 152 m led to the i=pcs-ioa oraimical pcn�w,=
oo=i_-!x of a fine ortp to s 1}oo.00 and/or caprizoaa,=orup to y' ead avil pmahio is d.form ora Stop Work Orde cad a
fim of S t 00.00 a day tpjall me
For dcp.+ta+..-al u.c oa77 _
/ Permit Ntimbcr
V/ PM—_ bol I
Siplatdrc ofLiaciscc/Pcrn-6ucc Date �
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
4 rt , K Not Applicable ❑
S Reaisteie Ffiome.firVik66 rK&&CQritractor
Company Name Registration Num er -----
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFF1DAVtT(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...... ❑
Ai
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 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 O`-u
SECTION 5--DESCRIPTION OF PROPOSED WORK(check all.applicable)
New House ❑ Addition ❑:,; Replacement Windows Alteration(s) Roofing
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[l3] Other
f Descri t' ned
efNork:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
s`a.{f New ito�isend orcdit�nexcsttnclatsiric�w;corpfef `the, ottO�niict°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?
L 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 AR CONTRACTOR APPLIES FOR BUILDING-PERMIT
1, 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
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
toll Signature Owner/Agent Date
Section 4. ZONING All Informatibit 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
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 0 DON'T 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# �
B. Does the site contain a brook, body of water or wetlands? NO Q DON'T KNOW 0 YES 0
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 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 0 NO 0
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 r NO Q
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Nortf ampton to
Building Department r✓urb era
212 Main Street skew �e F
'etC`uaaiCi �
Room 100
Northampton; MA 01060 us' ?��
ffft "a
1
phone 413-587-1240 Fax 413-587-1272 Rremut ans �
QtheSpecif} t a
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
This section to 6e completed bK office; _.
1.1 Property Address:
. Map Lot Unit
33 G19yfi,,CLDl�
Zane Overlay District
EIm St District'p C6
SECTION 2',-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Mailing Addre
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
com leted by ermit a2vlicant
1. Building (a)Building Permit Fee
/S"w
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) Check Number
This Section For Official Use Only
'Date
Building-Permit Number. Issued:
Signature:
i
Building Commissioner/Inspector of Buildings- Date
33 GARFIELD AVE BP-2005-0296
GIs#: COMMONWEALTH OF MASSACHUSETTS
MWX.R1Mk: I7C-074 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-2005-0296
Project# IS-2005-0391
Est.Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa. ft.): 12109.68 Owner: FOURNIER RAYMOND P&CAROLYN D
Zoning_URB Applicant. FOURNIER RAYMOND P & CAROLYN D
AT. 33 GARFIELD AVE
Applicant Address: Phone: Insurance:
33 GARFIELD AVE (413) 584-4575 (�
FLORENCEMA01062 ISSUED ON:9113104 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL PELLET STOVE
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: Receipt No: Date Paid: Check No: Amount:
Building 9/13/04 0:00:00 3688 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
33 GARFIELD AVE lot BP-2005-0296
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-074 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-2005-0296
Project# IS-2005-0391
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 12109.68 Owner: FOURNIER RAYMOND P&CAROLYN D
Zoning:URB Applicant: FOURNIER RAYMOND P & CAROLYN D
AT: 33 GARFIELD AVE
Applicant Address: Phone: Insurance:
33 GARFIELD AVE (413) 584-4575 Q
FLORENCEMA01062 ISSUED ON.9113104 0.00.00
TO PERFORM THE FOLLOWING WORK.INSTALL PELLET STOVE
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:,g fC
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON-VJ01 ATIO OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 9/13/04 0:00:00 3688 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo