17C-256 (3) 4'S11AA1P�.
�85EACt(li8[tt6 -
d DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building '
Northampton,MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sups. ,,i sor. T he 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 rouizh 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
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DEPARTMENT OF EUILDI?�G INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
WORKER'S CO1,14PENI SA'MIN INSURANCE Al,FIDAVI.T
i
%with a principal place of bus1ress/r,2sldeuce
ldlhone '}
(StTCCUC;I '......1:/"iii)------- -- - ------..�
cio hcreU}` CCrill}, t!nClcf" the 1)?.1i1S 2i7(3 pCi7 iilCS ni pe;rJtlfy i.Ili!i:
O I am an employer providing the followint v.,orr_er'-s comp nsarioll coves'-�.c or my
t;111()10yccs wor'Klrl on tubs job
(ln =C.n Comp=y) c C- N t I M,bcr) — (Expir Lion Date)
( j I am a sole proprit tor, genera conk or or t:onlco.vner (c;icie one) and l:a.,e 'tired
tl1" contractors IisteC below 1} 0 i; the tfJ1 .-� v or ite S coiIlpeIl 101-1 o!1c!tS:
(- amc of Contactor) Dmc)
(Name of Contrctor) -- r711sJ :race Con p .�,Pe!ie; Nlntrr) (I ?: i- tioa Date)
(Name of Contractor) — (lILS'�li1C^ (_O :'_il'i/i�0!.Cr T�11Ji]1}_Il 'X.iiC: O 1,atc)
- (N `of Contractor) —- jnS1:i-LjI1C_ CoIL11-7}`POUC-V Numhr_r)
^:t1Lt �3t:CY:17 5::;�t...._'_.. ::] ......�.......:K:..a....� ,�._.... � _ell_:...-..._...•
( I I1IT1 11 OlC l)1"U4)rl"CJi i'.iIQ hL-1,C 110 one- tot- ?II".
<? home 0vVI1C': i)CiIC -.l?1111 111
*JO"I�::please t>c nt��:c t}s:•.��•ilc F.c<;�o�+1r_n•.� -o c_,�!�;:1--t:-::::n:'o��c:_:.uac�ar::_n:r_��-n cr:c,�air�>-,:i:,r_�«cl!i::�'.
not uxre Lh a L reo Lmis in ut `t he t r.,�;uZ,�rte; s u<a;'` ✓:.-.�z uricr r I LhcC.o e c ext Ec xr�lly cc ::: :c h
catptoyc-3 uz&cr tFr tvc:�'�s ca --;_tire itc'(C)L.!S2 ;!(51 ,-r•1:_„ic:.^y n homco,,'txr for n l ccu
Icgal ctat)jc of nn caxptoyer under tt:o Woriccfa Con:;oration!.cy-
1 uz--8--zta d dlt a copy of!lui ctita:c_•may bo fau v o-I to tt»tY_Sxi tzrs> of I1-dzuiricl Ac6,,. &Gifcv of is :rar_o for tlx
coverlgc va-if c:1i0O and that tathttc tO!--”-m4 r y1- ci.IM 15A of?.tGi.152 can lead to tlx imposition
misting of a rtnc of up to S 1,500-00 nrJ Y i :pr Z :_of::p to c1-,:y -_j civil xrutl a in c tc r n c(a S!�,`•VMY.Ch�_:d
Lr�of S1 00.W a dsy glut):.1 m:.
Fr,c $r�uutYrtal u.c c.,ty
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Pcrrnit
5t r;vaturC Of l.icCnr CJPcrn,;a1-.
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holde ba"j,'/ 6rt,,e, —
(� C J� p License Number
/ h
jAddress �OX C,5- 4?ry eJ d /0 Expiration Date
gnature Telephone ( j
Regis a orne mprovement �.a'., Not Applicable ❑
Company Name Registration Number
Address Expiratiod Date
pTelephone
SECTIOPf 10 1NORKERS' COMPENSATION INSURANCE�AFFIDAVIT(M.G.L.z. 15!2, § 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.
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
SECTIOAYS=D S R:1PTONOFPsROPOSED�aiYORK check a11:a licaile
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ J
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No /
Attached Narrative D Renovating unfinished basement Yes c/ No
Plans Attached Roll 0 • Sheet 0
6a <fi teHr e �11i tlit on exiistin-SOM int°�co I:e fhe fiot°lawcn::
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?L41eS rl �
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 .
1. Septic Tank City Sewer Private well City water Supply
SECT101 " ��IR�UHORIZATION 'TO BE COMPLETED WHEN
OWNERS AGENT O�XNTRACTOR APPLIES FOR SUIT DING PERMIT
as Owner of the subject property
hereby authorize /G k�q 1�Gt WSOyt - Pki to act on
my behalf,an a ma lative tQ work authorized by this building permit application.
Z-�zw(-,Lo
Signature of Owner Dat
a OOwwneV/Authorized Agent
hereby declare that the statements and information on the foregoing application are true and accuCate, to the best of my
knowledge and belief.
Signed under the pains and penalties of perjury.
Prints Na
e -�
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
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 Sp ial 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 Com ssion?
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
',Building Department
` 212 Main Street
` Room 100 a
- No`Irthampton, MA 01060 e
—Pt ione�413A587-1240 Fax 413-587-1272 t.
kPPOCATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1- SITE INFORMATION
...
;, This secttorita becompfe#edbyAo#fic"e� "
1.1 Property Address:
/ r1 �f Lot' tt
r`qg Zone O'verlaDistrtct .
i rC H L C M A ,
Pg
' � H� ,
.k�y, '.h "' t
Elm St District CB Des rict�
SECTION 2 - PROPERTY OWNERSHIPZAUTHO,R:IZED AGENT
%r 2.1 Owner of Record: f
Name(P int}• � t C ent ailing Address:
Telephone
Signature _
2.2 Authorized Agent:
y, was V N 6 re f n-2 (Y/ ' i'` .,� � 8 orJ3'z C
N me Print) Current Mailing Address: JAI Y
Signature Telephone
5E0TION-:3 -fSTIMATED CONSTRUCTION<'COSTS
77
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant -
1. Buildings (a) Building Permit 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) Check Number
This Section For Official Use Only
i
Building Permit Number:
TDatelssued;
Signature:
I' Building Commissioner/Inspector of Buildings _ Date'
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46 iL 1"H MAN ST � BP-2004-0453
GIS#: COMMONWEALTH OF MASSACHUSETTS
A+an:Block: 17C-256 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0453
Project# JS-2004-0655
Est. Cost: $4000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Tom Dawson-Greene 124106
Lot Size(sq.ft.): 22389.84 Owner: BRILL ELISSA
Zoning:URB Applicant: Tom Dawson-Greene
AT. 46 NORTH MAIN ST
Applicant Address: Phone: Insurance:
P O BOX 556 (413) 296-4421
CHESTERFIELDMA01012 ISSUED ON.10121103 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE GARAGE & BREEZEWAY 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• Receipt No: Date Paid: Check No: Amount:
Building 10/21/03 0:00:00 8436 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo