17C-127 (4) HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supervisor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or hvo family
divelling, 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 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
understand the above.
(Home ow er/resident's signature r nesting exemption)
I will call to schedule all required buildin inspections necessary for the building permit
issued to me.
Date �22
Address of work
location
p� e of o rtllaillpf till ( �
< - ' �a5DA(h115ct15
DEPARTMENT OF BUIL)PIG IPJSPECI IONS
212 Main Street ' Municipal Building
Northampton, Mrnss. 01060 _
NVORKER'S CONI fP NSATION INSURANCE A F-D,,'�V1T
(11 C'nSCC�frInllit:^)
v"Ith a 4cipal place, of busuless/resideuce at
------- - -- - ---- -- ----- - (phon •\'-- -
(Stre�.Ucit}'JSia^��-'�)
d0 he(6y Ccitii'r, udder the ji2!i]S ;1111Q pellaltiC s Oi pCfjtli}"
I ani all etllplo}'CI pm,"Idln- the OI"r:C!"S C01Ilt�Ct1SCI'011 GOVT.:<i_;C lOr In�'
e111plOyccs "vul�-ll g Oil L11b)Ob.
I am a sole pfoulic"0I, S�lcni:ral CCTl',f-, e Uf C!OnI �CflCle, oilf;) dlld, lll?VC Illf l
t_he contractors listed below who have the foll v,11:, Coll oens�'0Pn oolicieS.
-_— (t'If me of Contractor) (1.I1sur-[lc:, COIP.*�?^jYhO�:�f 'Numb--) (L-.'.i n t1Cfl DatC)-
t-Name of Contlacl0r) l_nsumncc coill,._.t,/1'011.7i (1:7.C[r..tlQ n 1]2tC)
(N!1111C of COntI ctor) (111S1if311� (�O[ l;1fi'i �,,'r 1 l Il.l,�Il [.S;i i..t_.on Date)
(Name of Cont:-nctor) (Insz.Iance Co ill r _�y, 'ol Date)
i 'ull a s()IC p1U})I1 CJi :iI1;1 ImVC no 0I1C ".'rCthl;i' tol iile.
�, IIl 11 11 0 111 0 O�V!1C: l'CIIO IIlII] all tI]: PJOir: ii:`rsClf
NOTE.:please t-n aware that.til i1c lx<;'co..r_z5«cn)e:;plcry
not mote tlLu tlircc unis in ttt_ie't the 1:xtiv.nr�rend ct oa to .– _:,�z vr:cr_u1 Lx o e:c[ax CcrraliV e::d:cd:o
caTloyca u :cr t1r_cvctlxt'�cc:ar__.atiaz r:.Li(GLIS?_s t(5)),n -'Gr_:ic;,by a hor:m tv:rs(�r Gib rc cc n:-r;:i:rte:c..:-ikc u._
)cpf ctithu of an—Tloya uz)�'r tl:a W"kti '.C%ocntxrratiocr Act_
I ucxlcnU.ud that a c -py of t1v.ctat—t orgy bo fcnti'nniod to tl;n lY.t t.,cc>I of Lusiztrial -i,;,:nt�Cfiim of L-- a for t1:a
co�'aa�c erif cation n that fsl uc to r-a e eoyt� un3 r seC.icn 25A e(?.(GI.152 can Ic 1 to the in[; sition of mnir l petslt:cs
ocxnisiing of a itcx of up to S 1�W.00 na,'cv i�Itrixx.�xr1 of up�on-y-rr r.n,j civil pcnaltiu in tte fonts o(n Stc;t Wm�Oni�and a
fir>~0(5100,W a clay a&tiinsI ar.
Fcr'<kp+:tarit�l u.o ally
-----�---
Map�I I,ot
1 193alturc of Liccn c-c/Pcrauttcc
Mt
h
SECTION$ CONSTRUCTION SERVICES
8.1 Licensed Construction Su ervisor: Not Applicable ❑
Name of License Holder
Lic/ )en /
se umber
Address Expiration Date
c
Sig ure Telephone '
Re s e vemeHA, ontractor Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION i10-1WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G L. c. 152, § 25,C(6))
j 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...... ❑
i
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinzs 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-vear 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
•. M
. i
S'ECThONS: DESCRPTIONO`F PROPOSED WORK chec"ll'a licable
f.
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
^r
Brief Description of Proposed Work:
v
Alteration of existing bedroom Yes No Adding new bedro Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet o
1`.f Ne you a ' "d o ddition to eXisting hou inf7 complete ttie' fo1`lo i-'M:
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
SECTION7a NE
OWR"AUTHORIZATION -TO BE COMPLETED WHEN
01NNERS`'AGENTOR CONTRACTOR APPLIES FOR BUILDING PERMIT,
as Owner of the subject property
hereby authoriz to act on
my behalf, in all matters rE ative to rk authorized by this building permit application.
Signature of Owner Date
as Owner/Authorized Agent
hereby decl r that the statements and information on the foregoing application are true and accurate, to the best of my
knowledge d belief.
)Print rider the pains and nal es of per
me e of Owner/A ent Da e
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 N W
K 0 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 KNOWN
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:
City of Northampton S atu.,, Per
A� d,
Building Department C bGutD4
212 Main Street S wer Se
Room 100 Wa er/We
Northampton, MA 01060 Tw4Set
phone 413-587-1240 Fax 413-587-1272 Plot%StePa �
11 11 Iginilis
OtherxSpectfy
•
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address:
This sectiobj be completetl by office
Map Lot ` Unit
Al,
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name (Print) ',:rent Address:
i
Fphone -
S fa ure
2.2 Authorized A ent: �_�,✓ '� j�
-------- -----------
Na"I1- nt) Current Mai!ing Address:
c
Sig oture Telephone
S TION-3'- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be, Official Use Only
com leted b�pern apEhcant
1. Building (a) Building Permit Fee
2 Electrical (b) ' :,timated 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 lumber -
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: _
Building Commissioner/Inspector of Buildings Date
I
BP-2003-0779
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0779
Project# JS-2003-1281
Est. Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin James Roberts 117154
Lot Size(sa.ft.): 11194.92 Owner: KULIG JOSEPH&SUSAN L
Zoning:URB Applicant. James Roberts
AT: 63 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
30 Edwards Rd (413) 527-6078
WESTHAMPTON MAO 1027 ISSUED ON:3124103 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• Receilpt No: Date Paid: Check No: Amount:
Building 3/24/03 0:00:00 1787 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo