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5" DEPARTMENT OF BUILDING INSPECTIONS
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INSPECTOR 212 Mein Street ! Municipal Building
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Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as ].]s/her construction sul)-:.: .i;or. The state defines "IJomeowner" 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
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
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DEPARTMENT Of' LIUILDII`G INSPECTIONS
212 Alain Street ' Municipal Building '
Nor thatnp toil, Mass. 01060
�'ORYQ�R'S
COM-PENSATION INSURANCE AFFMAM
— ----- (]ic�nS:.rJtcrnlittcc)
,ith a principal place of bushmsdresidence ar.
rc t/t.1t}'s y top)
do hereby certiiv, mAr the i illd pcnt!lties
O I a.in an employer providing the following; wolei's compensation cove;-,,.;c for In),
einployecs work-irig on Cnis job'.
(Ilsuu1CC Company) (Polio:Number) ( ,piraon Date)
O I aai a sole proprietor, yneral contractor or homeowner (circle one) and Have Hired
the contractors listed beiow,,'ho have the follovvwl, workers compensznon pohnos:
(Name of Contnctor) iInsur-a ncc Comnany,Tohcy Numb---,) Ez::rattcr. Date)
-- (NdII1C of Convamor) onsumulcc Comb :1y/POLICY Nutilbcr .__ }, ,., ii101 Date)
(Name of Contractor) (111SU=C`1 Company/Police N111I1lxr) -.x;::r.:doa Date)
(Name of Contractor) (Insurance Comrr-llylTolicy Numb--r) (Expration Date)
(attadt>�itimil ci;.-ct if r.eccz.:-:t:: ��r_'.:�i<::_:csutiiee rc ta:nicg t:.ell c-<:7aa�:c-)
i
O I tun it sole proprietor t:n:i have no one workng for me.
I aIIl < holne oAV!le:- he!Iorliling all the D101:•:iiiyself.
Noll:p!c ac be a«uc Lta;•.s' lc tx<1 o.t:r .a c. p!oy Ir-z :s .>c�rlrunc�cv r m cr: ;;air cl!t
not nmec ti>_.n Uuco uuitf in���::�'t'Fr!:r,1��•,izrr rn�a cr oc:t.`..,E:-��:y's zpFurten:rrl thrRo e:c txl(;ursally c._<'::::::: :�h
e�tploy�uy er t}x.twtl:er'�ecr.>;Y:etim P.d(GL152,=31(5)).z{�•Ca!iea by a hotnm�tirer for z licnu er per::i:r.ta-:ec1.:r5x tr=
UPI Axtrig of an ampwyx mom on WNkw.Coro—i oku Act-
i WA=awd on a copy of this ctit--Iii ir.y Lo fov—v<dod to tl»Dctnrtrncnf of lnaiutrial A,066 fy Oifio of for 0-
oovc tgc vaificatioc and that f:ilurc to tcauc covcmgo ut:3-r stction 2 5 A of Md1,152 can!cad to tha ifrr{ros iia °`c i i l pc uL':cs
ownl mg of a&C of up to S 1,500.00 n: 'x in:;rrisx nx of up to cr>:yczr AM civil pcnaltia in dY f" of a Ste W at Ord-: and
fine of 5100.00 a city igninsl rr.
For dq;utnntsl uic cx:ty
T-5,
� aturc of Liccn�;cJPcrnl;ttcc t��
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SECTION 8=CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
f's"fe*Me -KK O"" m r Ve61 lilac-AR'Ctor.' � ;-
R - N ,x �r� �? Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.-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...... ❑
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. t
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
I
j
SECTION'S=DESCRIPTION OF PF20POSED WORK(checktalI applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. Demolition❑ New Signs [ ) Decks [ ] Siding[ ] Other[ ]
Brief Description of Proposed Work: ���'1 `'Y MAC)1-" 0 G }�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll 0 - Sheet 0
6a f-INew h6ffs-e a dd o° addition to<exi§fing4ffd fng,a,,co mpWbe the folfowin :
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
SECTION 7a OWNERlAUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT Q,R�CONTRACTOR;APPLIES FOR.BUILDING°PERMIT
I, 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
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
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 G /- r
Setbacks Front
Side L: R: % L: R: '
Rear
Building Height 7
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg&pavedO
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: / ?P.5
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 Statuskof
Building Department
r
2,12 Main Street Sewer/Sep i�" a e . .
, +t- Room 100 WaerlWe` Va k r
Northampton, MA 01060 Two Sets of Str c ra an
A,G�pho le _J 587-1240 Fax 413-587 1272 Plot/Sete"Plans
I &Z t ' � �
Other Specify _ �
APPLICATION TO CONSTRUCT;ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to be completed by office"
1.1 Property Address:
f
6 N ^� Map i✓ Lot Unit
4,
Zone Overlay District
Elni St. District___ ,_ CB District_
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) , li g Address:
^� Current tJ�ail�n
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
____T_
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (DollarsLlicant
be Official Use Only
—completed b permit a
1. Building 7il . (a) Building Permit Fee
f
timated Total Cost of
Construction from (6)
3. Plumbing ��/ Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (? + 2 + 3 + 4 + 5) Check (umber —" _
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature: ----- --- - ---- —
Building Commissioner/Inspector of Buildings Date
File#BP-2003-0837
APPLICANT/CONTACT PERSON PADECK EDWIN M&JOAN F
ADDRESS/PHONE 29 FERN ST (413)584-9299 O
PROPERTY LOCATION 29 FERN ST
MAP 17A PARCEL 274 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 7S
Typeof Construction: ERECT 8 X 12 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF RMATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street Commissi
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A.Contact Office of
Planning&Development for more information.
,y BP-2003-0837
GIs#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot:-001
Permit: Buildinci
Category: BUILDING PERMIT
Permit# BP-2003-0837
Project# JS-2003-1362
Est.Cost: $1700.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 5009.40 Owner: PADECK EDWIN M&JOAN F
Zoning:URB Applicant: PADECK EDWIN M &JOAN F
AT. 29 FERN ST
Applicant Address: Phone: Insurance:
29 FERN ST (413) 584-9299 O
FLORENCEMA01062 ISSUED ON:4117103 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 8 X 12 SHED
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 Occupant signature:
Feel e: Receipt No: Date Paid: Check No: Amount:
Building 4/17/03 0:00:00 3743 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo