17C-132 � J�Tlassacflusrffs
DEPARTMENT OF BUILDDNG INSPECTIONS
cCTOR 212 Main Street • Municipal Building
s
Northampton, MA 01060
tr
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.-s.or. 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
r 9 '
?° tea:"°ti (rLii of YortIjailiptall
Q F 61xalwchnactIS'
DEPARTMENT OF BUItDf\IG INSPECTION'S - —
212 Main Strcct Municipal Building,
Nrorthampt.on, Mass. 01060
tVOILnrRISI CONOENSA'1710N -MSTn?.A-NCF A FLY AVi-r
(I1 CL:'IIS:,t/pCT'II1�t ICC)
with a principal plat,- of business/residencc at:
(su-r-.t/ci ty/staicla p)
do hereby cerdi -, under the.p?-U'IS and penalties of per3ury, :hat
( ) I am an employer providing the following %.,orl:cr's comocnSaDo, cove rzgc for 1ny
etnplovecs «-or.Ung on tjIis job:
jnsux-_n= comp-am') (Pclicr Nu.macr) --- (-E--,pinion D2j--)
O I am a sole proprietor, general contractor or homeowner (C'Lrcie one) and have hired
the comsat <prs Lsted below wbo hive the following worker's cocnpns 'on policies:
("NS ID: 0i C0n-Mctor) (InRranc:c COITIpa,-I)-iPcUCi ��turIlLCr) -- �`-JtiJU^� Datc)
(Name of Contractor) (1ns,Iranec Compan-;/Po!ie; Numc-:r) (-E.kDir.:tion Dale)
(Name 01 Counaao,-) Onsuraac= CoMT=)-/,Pouc)- N:Imb ) (Expirzdoo Datc)
(Namc of Conizaaor) (Insuiaa(ti Company/Policy Numb--r) (Expiration Datc).
(air d i ocnl 6c,=.daccca-y to a�cuc�c iaformuoa pc�ninia6 to.11 t
C
I am a sole proprietor and bave no one wor4dng for me.
( ) I am.a home owner performing ali the work myself.
NOTE:plesc be aw2rt t5,,...{ }e boc c=,n uto ploy D='Low to Lb m•:•-„-- W,—zcjJO cr m Sir work on.d-. a---,of
not mote the Lbro tmitt in tvixeb the botnornwcr rt=de oc oc the Qara6>.7�tbcco c.-r ooc C=>rity oocrd=d to be
cnploye-z u' the--k=m C=P ,cc Act(GLI52=1(5)1.=.pPt+abon by a bomcom-oc fcr_lice.or Permit ray n7deaee tt:c
Icvd its of ea a)loyx coder tic Worcorc Coci�Ac(-
I d th r x copy of tbi,mrem=m my bo .Lb. CC,-or Ir=�ro<the
cova7.se vcif t3lioo and t!u L-ihac w scary,-tovcrn&e under soecion 25A Of),(GL 151 as lad to the L-P i oo orcimi PcaL16=
ooesisag or 1 rrac orup to S 1 500.00 endfoc iMpc o(up to ooc yr=r end coil pautia to the foci o(x Stop Woric Order and a
rim of S 100.00 1 day crPI=me
For d�.run= u,c ocily --- -
f l 1 pc='t Number
GG ._._-
IOt
Sir,—Lure of Liga�C-MIiLtcc �� --
:TION 8-CONSTRUCTION SERVICES
Licensed Construction Su ervisor: Not Applicable ❑
,ame of License Holder: i
Number
17 License Nu�� � -✓ � J
Address Expi`ef nDa
Sign at a Telephone
.Reui`s"fere"i�ome�l°riiprovetne O tt G Or ,q� �_` E- a
_ ,.� •. Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION`INSURANCE,AFFIDAVIT(M.Ga.c.1'52,§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...... ❑
MEN-
FIN
I'M � '
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-awn-a-parcel_ofland 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, hat 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—DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors E
Accessory Bldg. ❑ Demolition ❑ New Signs [O) Decks [M Siding[0) Other[C])
Brief Description of Proposed
Work: � �(
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa I tVei� Fi Nelm VM
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
SECTION77a=;—WWER AUT;HORIZATiON.� O BEGQMP�ETED 1lY1iF�t -- -
01NNERS:AGENT.QR°CONTRACTOR"APPLIES FOR:BUILDING..PERMIT
�. 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 her?hy 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
/�'L1,l�"
Signatures of Owner/Agent Date
^
�
'
Section 4. Z All Information 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
Rear
Building Height
Bldg.Square Footage 7---7 %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Varunca/FindinQ ever been issued for/on the site?
�� �N
NO �_/ DONTKNOVV tj YES �.��
�
IF YES, date issuod:
IF YES: Was the permit recorded at the Registry ofDeeds?
NO K } DD07KNOVV YES
~-=
IF YES: enter Book Pogo and/or Document#
��
B. Does the site contain abrook, body ofvvotarurwetlands? NO U] DON7KNOVV �~� YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained Obtained ~��~� Date\~� � ' '
C. Do any signs exist on the p,nporty �� ��V 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 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre nris it part ofa common plan
that will disturb over 1acre? YES y ) NO ��� }
IF YES,then a Northampton S1nnn Water Management Permit from the DPW is required.
`
City of Northampton
Bu ding Department
212 Main Street .
Room 100
1 '
ff$jihampton, MA 01060 'u
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,-ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTI014-1.-SITE;INFORMATION
1.1 Property Address.: tt Thts��ectrotobe�coitlp leteclbgffice
y mS & ra.
°Map
:
max X
t r
4.
SECTION 2-PROPERTY�OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: ve
"e-ri I� 'r�i !1��1� Yom'°?i-� / LC� 4 o ck2
Name(Print) Current Mailing A dres ///,1/i'5X f _�
Telephone '> ((,
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED`CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit'applicant
1. Building -,(a)�Building Permit Fee
2. Electrical ✓/ `� '(b),,Estimated Total Cost of
Construction-:from.,6
3. Plumbing Building Perrnit`Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check-Number
This Section For dfficial"Use Onl
Date
Building,Pennt Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
CONTRACTORS INVOICE
- r
WORK PERFORMED AT:
TO: fion
oto
-"3 3
DATE YOUR WORK ORDER NO. OUR BID NO,
7
-art c etrove- 0 f
5
Y
ltd. f; u*1 t'
04 on
(Orr) UUU
job n
All Material is guaranteed to be as specified, and the above work was performed in accordance with the drawings and specifications
provid fthe'ab v work was completed in a substantial workmanlike manner for the agreed sum of
,
"Z
e�.� ., f Dollars($ t ).
This is a El Partial ❑ Full invoice due and payable by:
Month Day Year
in accordance with our ❑Agreement ❑ Proposal No. Dated
Month Day Year
MADE TC8122
USA
ad— MADE IN CONTRACTORS INVOICE
BP-2007-0441
103 HIGH ST
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.-Block: 17C- 132 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-2007-0441
Project# JS-2007-000655
Est.Cost: $15000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: AMERICAN CONSTRUCTION 141721
Lot Size(sq.ft.): 20691.00 Owner: KOWALESKI ELIZABETH G
Zoning;URB Applicant. AMERICAN CONSTRUCTION
AT. 103 HIGH ST
Applicant Address: Phone: Insurance:
187 WEST ST (413) 433-6882 O WC
HATFIELDMA01038 ISSUED ON:1011712006 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP SLATE, INSTALL PLY & 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 Sip-nature:
FeeTyUe: Date Paid: Amount:
Building 10/17/2006 0:00:00 $25.00MO
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo