10D-007 (4) 4,ttlpaip�, !
�i itSSiltr�ltSt�S
DEPARTMENT OF BUILDING INSPECTIONS �
INSPECTOR 212 Main Street • Muiucipal Building 'Q.
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNdR 108.3.4 to
act as his/her construction step<_s ,i s. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be a"one"or-tvo��
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."
Tlie budding deparffffent_f`or the C`ty oTNanhanrpton-wants-anyperso -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
L understand the above.
(Home owner/resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
- -
is-sued-to ire.
Date
Address of work
location
r
4f '.Irlrfltallt�fDn
DEPARTMEI-ff OF DUILDr),ZG lNSPPCTIOtdS -
212 Alain Street - Municipal DuIlding
Northampton, ATass. OIOGO
«``'ORItLR'S CONS PENSATION MSUR -NCE Al�I'II)AA�ZT'
(Ii�ns�Jpc;mi tttx)
-,%,I Lb a principal placc of busiDessfresidence at: - -
,honer
do hereby cerdi --, under the.pains and penalties of pcgu-ry, '-hai
( ) I am an employer providing the iollo.ving;«oriccl✓s comocnsatio, coverage for my
eluplovccs wortong on uus job:
i (L.nu--n=Conr ) (Pollen Number) (r:-pimdor.Dzi--)
( ) I atn a sole proprittor, general contractor or homeowner (cc;-- one) and have hired
i the consaciors list-d below c,,bo have the foil wjop, worker's comoen_�don po5cies:
o �i1ffLr.) -- fr':>3rJL°Oi?D.11c)
� It+IIril: 61 C0�'.^QO') (lti_Riranc;: COIIlDI7T}"/hGUC=i ��
,
j (Namc of Coneacior) (Ins -ancx aMvaQYI?O!ieti_• Numb--r) (E»+riion Date)
(Name of Conaacto-) (Irsu-dnc-- Compare}-/Porky Nambu) (E.xpiraos Datc)
(3`tatne of Contractor) gnsuraa= ComrzuyNolicy Numla r) (Expiration Date).
f,atlat� •Kr;�nr�iJ bca..tn�-.-}-w c�c'u.�iaf«m+is-oa pcZaiaans to.11 coc-lo:3)
j �1 � a sole pFOpr etor and have no one world.ng for me.
( ) I atrl:a home owner performing au the work myself.
NOTE:pica be cvrart o- -�tet6emcn.�x�a_b,ploy P==w di c, cs e�oo a rc}za•Vrk as.d%'MU--�of
act(tl]OCL I II L�1"b:L}YJ zn\aln. C.�jl�[avmom�"DC r'Qld�OC OC�c II9ti.y�1 ' ^r St)C"�D LT ooc�-==--Ily occ:d.-06 be
.::6pIcx=I, the-- ct c.Act(GLil52.=I MI zppti=.6.by.bomma-=r fc c G -- -or pe=lt=r a-id=cc t1=e
Ies;-t r„c.c of ea a-=Pioy«under do WorSeda co,=P. y o/,ems
I d tha a aop).of my be for---d..d to ttw O pre,tm or Lo - j Acodenc'Ofs-of is..r.oae for ti.
cave sc veilezioa z M the r:ilzse to soauc Lrovc aae trod=soe oa 23A or MOL 157 na 1--d to the ia�oa of--iasl pe ,W-
00—=Ms of a fiat of up to S 1300.00.rdfor orup b oac y-.s c.ad evil pcozlUa is d.-rot=of.Slop Wort Ord-- .red• _
file of S 1 00.00 a d_y t.^pias1 MI-
For d4�=J u,c on77
pc=t Numb r
Lct
S4aaulrc of LicasclPcrmiuc Late J
SECTION..8--CONSTRUCTION SERI/ICES i
8.1 Licensed Construction Supervisor: /Q Not Applicable 0
Name of License Holder: Ob_
License Number
Address Expiration Date
Signature Telephone
�e re• m the, Not Applicable ❑
Company Name Registration'Number —"-
Address Expiration Date
Telephone
SECTION 10-,WOFZKtRS'COMPENSATION='INSk 1P%t#GEA:EF1DAVfFs(NFf 152, 25C(&yj
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavft 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 1083.5.1.
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
P,
SECTION 5-DESCRIPTION-OF PROPOSED W.ORK(check alt.applicable)'
New House ❑ Addition ❑; Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[E-3] Other[E7]
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
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,;OWNEI2.AUTKORIZATION -O�BECOMPCETEfl Yl HEN
:OWNERS AGENti OIL CONTRACTOR APPUES-FOFVBWL"DIiYG PERMIT'
c
as Owner of the subject
properIF
hereby authorize f'V
to act on my behalf,in all matters relative to work authorized by this building permit application. !�
Z2:4zzze�<5
Ile
Signature of Owner f)atp
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
Signature of Owner/Agent Date
i
Section 4. ZONING 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
s
Lot Size ` ` ---
Frontage
Setbacks Front ! '
Side L:' R i L:�� R:l
r—
Rear �--=
Building Height
s
Bldg.Square Footage % �-
Open Space Footage %
(Lot area minus bldg&paved
arkin
#of Parking Spaces
Fill:
t
I
(volume I&Location) IL
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q 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#!
B. Does the site contain a brook, body of water or wetlands? NO 0 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 0 Obtained Q 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 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 0
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
OF +
City of Northampton
BwOding i3epartme nt
l 12 Main Street
Room 100
orthampton'. MA 01060 M
�r bn 3-587=1240 Fax 413-587-1272
_ .
A Rol iCATION?O,CONSTRUCT,4TER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING m
SECTION 1=SITE INFORMATION
r Thrs sectron to be completedoff�ce,
1.1 Property Address: " a
Ldcr�
� o�� �; �r x� �,Ovei•7ayDls�ncf. �� ..
� f �
Elnt=SE^DistcL' srCBct ,
SECTTON 2 PRO PERTYOWNERSHIPIAUTHORIZED AGENT R
2.1 Owner of Record:
Name(Print) _, Current Mailing Address:
Telephone
Signal e
2.2 Authorized Aclefit:
Name(Print) Current Mailing Address:
0,0,&. cry 96 ::�) l3 �'
Signature Telephone
SE--TION..=:ESTIMATED-GONSTRUGTfON=COS TS,
".
Item Estimated Cost(Dollars)to be Official Use Only
com feted by ermit applicant
1. Building �D 0 (a)Building Kermit 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) l:heck'Number
ThivSedt dR F&i Ofr1di;ff.Use.OnIy
Ebifdin Permit'�lumber Date ,
g tssU.6' '
Signature: r
Building Commissioner/Inspector of Buildings.. - Date
91`v1fATER ST BP-2006-0291
GIS#: COMMONWEALTH OF MASSACHUSETTS
MU:Block: IOD-007 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0291
Project# JS-2006-0423
Est.Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: DA Williams 108011
Lot Size(sq. ft.): 13895.64 Owner: BERGERON LEONARD O&LEONARD
Zoning URB Applicant: DA Williams
AT: 91 WATER ST
Applicant Address: Phone: Insurance:
81 Water St (4131 586-3139
LEEDSMA01053 ISSUED ON.911412005 0.00:00
TO PERFORM THE FOLLOWING WORK.-SHINGLE ROOF OVER 1 LAYER
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• Date Paid: Amount:
Building 9/14/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo