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m DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060 5
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as has/her construction sups .• sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fancily
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
4�ILAMP
lS-If h1 Llf l7�" (��Z7ll�l Lill
♦ �1�iSSAClj iib[ii�
. m DEPARTMENT Of' BUILDING INSPECTIONS
212 Alain Street ' Municipal I3uiicling
Northaml}toil, Mass. 01060
WOP.-TCER'S COM ENI SA770N INSURANCE A.T+'FMAVIT
1
%,ri III a principal place of busiresslrc:-jiccnce at.
-"---�-
do hercby Cer—ujy, LI];1 r die l)i ii1J i?iid OCil?1t1CS C)i 7ef�lll�r
( ) I am as employer proviciin- the follo`vint colnnensation covcrr: e or Iny
erllployces worbr]g on dus job-.
(Las-,=cc ('onp.mv) tr`t 11>cr)
( ) I a -i a sole proonetor, ze"'ItTLI homcowoer ;circle one) and, t]a,re tureu
t_lic contractors listed below-] to l-, „ the Polo
,Na-mc of'"'ontmc-Lor) (InSUaI1C Col IGi1Cr T1L1Sn i) T.?'; DatC)
(Name of Contr<.c nr) /Po?ier UM, (E. r tinD Date)
(NIame of Contractor) Inns�s}ce C. - - -, 1 _-..
� 'oL•�. NuJirer) :.�,. �t.oc ;ate)
-- (Name of Contactor) --- Jos-1 ra ��omr_--y r o—licy-`---�-- -�_ —Date/
-
l.`..C1•"�I:1 CY:1I i::_iS...._-_... _ .n.-._. .._.":Y-..a..,n ,--....... rli.�:t:'_..-...•-)
l V6 Lll is mole pl Oj?r]CtJi ii:11 ilave 1 oilt, . ' ;! i]e'
( ) � � i O for ills.
i11 a home
?d0'TIi:please be ntva:c Lst•.ti�:i)c]x<rco.�ir_r;t,-o c �L.^-,;r—,::;n::�..—�c:�,�.ac�a.: n:���m cr:r,^air t.,':i:�-:_d�rc!!i::�c.
not umce L'Lp thrvo uni±i ir:«-!:dt;he 1,:.-.:ti� a��_re::.��or oc;•�><.�;•_.-.���*utter�rS LhcRO c,-c rr�{�-rsall.i o:�::::::c:;:a t�:
eatployc�uti!er t}r tvc;i:cr s cc x- cc Ac (C3L!f3 c!(51;.n<=,•._;:ic;:by a hoc tco r `cr e Gccx cc pcz;:i:: n e _c
lcgzl rtztuc of an amploy♦r undo tL•o Workcx�c COM,>m_- 6,3,n;A.cL
I undeztand the a copy of thi rtatG,_�r_uy bo for---d-3 to tl»IYtL L ua of Oir—of for t1x
covcngc vcriGciioa and tlht f iltuc to:-z -'coti r;ut cC.iM 25A of MC-L.152 ctn lc--,d to tl>c impozitiat
misting of a fur_of up to S I S .00 zn:'re of up to nn:)-,-.r-.:er.j civil perulUa in dK;c-,nn of a S!r,
f r> of S l i}n.pp a iy�raina mc.
-- Fo,6q—' f-ll u.c c�lly I
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SECTION SCONSTRUGTION:SERVICES
.............. .. ..
8.1 Licensed Construction S,ul2ervisor: L Not/A�ppl/icayble ❑
Name of License Holder
License Number
EaW' laiq JP yu HAS 'z7--6
Address �j Expiration Date
Sign e Telephone
ve en Ton'tr:'acto - Not Applicable ❑
i?26-00 00 I N( Sl -br 6c,
Com any Name Registration Number
Address Expiration Date
Telephone
sSECTIDN U WOI §R' MPEN ATI 1 htSLIRANCE.AFFI DAVIT;'(M G:L .c. 152, § 25C(5))
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 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
SEC p l w B. PST O OF ROPbSED NORI( check�aif a Ilica: �
t
New House ❑ Addition 0 Replacement Windows Alteration(s) ❑ Roofing I/.
Or Doors ❑
Accessory Bldg. ❑ Demolition[] New Signs [ j Decks [ ] Siding[ Other [ )
7
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll D• Sheet 0
dTUGH5,17 sfing h.ou Ong,.c m� a=e he ilow.i:ng:
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 .
f. Septic Tank City Sewer Private well City water Supply
m
SECT®N ERTORIZATION TO BE COMPLETED WHEN
0 PCEftSA�� O�OvN�RACTOR'APPL{ES FOR SIfILDING PERIVIiT ':
I, SS aK,� as Owner of the subject property
hereby authorize -�,�� CJ ( �(1 b to ac;. on
my b�half, in all tters relative to work authorized by this building permit application.
t<tf .
Signatu of Own DateO
I, j 1 1 l uti as Owner/Authorized Agent-3
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.
:V-) 16 D0 -
Print Name
Date
Signature of Owner/Agent
w
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 KNOW 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 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:
City.of Northampton
9wilding Department
~' 212 Main Street
Room 100
U - 1 L005 Northampton, MA 01060
hone 41 .587-1240 Fax 413-587.1272 t
APPLICATION TO C T, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
This secti:ontolicom ate"Ybyo face
1.1 Property Address: ^• �x "
Zon Overta; D�stxt
SECTION 2- PROPERTY OWNERSHIP/AUTHORIZEDAGENT
2.1 Owner of Record:
Jess Ica, ,(-a�j IV,' Cl es �4 2�S71 arr_12&,
Name(Print) Current Mailing Address*
A
Telephone
Signature
2.2 Authorized Agent:
Nam Tint) Current Mailing Address:
Signature Telephone
SECT10N.3 ESTIMATED'CONSTRUCTION'COSTS4'''
Item Estimated Cost(Dollars) to be Official Use'Orily
completed by ermit applican t
1. Building i,� (a) Building Permit Fee
6i
2. Electrical (b) Estimated Total Cost of j
Construction.from 6 5
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 Onl
Building Permit Nu mber> Date Issued:
Slgnature`'
Date
Building Commissioner/Inspector of Buildings
T
229 CHESTNUT ST BP-2006-0118
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A- 137 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Caterv: BUILDING PERMIT
Permit# BP-2006-0118
Project# JS-2006-0177
Est. Cost: $6500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Robert Thibodo 118441
Lot Size(sq.ft.): 35457.84 Owner: LAPINSKI JOHN&JESSICA
Zoning:URA Applicant: Robert Thibodo
AT. 229 CHESTNUT ST
Applicant Address: Phone: Insurance:
P O Box 201 (413) 586-0391
NORTHAMPTON MAO 1061 ISSUED ON:811105 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 Sienature:
FeeType: Date Paid: Amount:
Building 8/1/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo