29-080 (4) City of Northampton
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t t `t DEPARTMENT OF BUILDING INSPECTIONS :� .
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212 Main Street • Municipal Building y ,,
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X 11 ; Northampton MA 01060' 3 �� '
INSPECTOR
Louis Hasbrouck Chuck Miller
Building Commissioner Assistant Commissioner
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
1 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 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
I, , L c-tL' cSI,, e--,, t2A . -_ .. = - 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 1 2--(Zi /bit)
Address of work location (7C 4- brZ z L : 10 c-e,_ A 01062...
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
9. Registered Home Improvement Contractor Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 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 ❑
11. - Home Owner Exemption
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''
0
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing n
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding [0] Other [X]
Brief Description of Propos d
Work: VI( + i�� (2.11,■m,u, k Wuvd sAve.„ o r lA twtvt2 Clef J e-wk
Alteration of existing bedroom Yes )( No Adding new bedroom Yes )c. No
Attached Narrative Renovating unfinished basement Yes
Attached Roll - Sheet
6a. If New house and or addition to existing housing, complete the following:
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 - OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, 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
I �l L c}d z , 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.
1
Print Name
tOd
Signature of 0 L gent Date
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
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 0 DONT KNOW ® YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW e YES
IF YES: enter Book Page and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 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 0 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES 0 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
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
Department use only
City of Northampton Status of Permit:
fl-s'\ Building Department Curb cut/Driveway Permit
212 Main Street Sewer/SepticAvailablllty
Room 100 Water/Well Availability
Northampton, MA 01060 Two Sets of Structural Plans
phone 413 - 587 -1240 Fax 413 - 587 -1272 Plot/Site Plans
Other Specify
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: � This section to be completed by office
re- 6 K Dr. Map Lot Unit
Flo /i' 6lv(0Z
Zone Overlay District
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT
2.1 Owner of Record:
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Name (Print) Cur nt M cling Address: _
7
Te ephon
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Signature C /
2.2 Authorized Agent:
Name (Print) Current Mailing Address:
Signature Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building � (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 /10
This Section For Official Use Only
Permit Number: Date
Building Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
f
File # BP- 2011 -0615
APPLICANT /CONTACT PERSON LODZIESKI SCOTT & MELISSA
ADDRESS/PHONE 45 Acrebrook Drive FLORENCE (413) 320 -1775 0
PROPERTY LOCATION 45 ACREBROOK DR
MAP 29 PARCEL 080 001 ZONE URA(100) //WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out //�
Fee Paid / 425-
Tvpeof Construction: INSTALL FLEX CHINMNEY LINER,WOODSTOVE,& CHMNEY CAP
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
INFORMATION 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 Commission Permit DPW Storm Water Management
Demolition Delay
/SO
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.
45 ACREBROOK DR BP-2011-0615
GIS #: COMMONWEALTH OF MASSACHUSETTS
MMp.Block: 29 - 080 CITY OF NORTHAMPTON
4
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: woodstove BUILDING PERMIT
Permit # BP- 2011 -0615
Project # JS- 2011- 000203
Est. Cost: $650.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 16422.12 Owner: LODZIESKI SCOTT & MELISSA
Zoning: URA(100) //WSP Applicant: LODZIESKI SCOTT & MELISSA
AT: 45 ACREBROOK DR
Applicant Address: Phone: Insurance:
45 Acrebrook Drive (413) 320 -1775 ()
FLORENCEMA01062 ISSUED ON:1 /10/2011 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL FLEX CHINMNEY
LINER,WOODSTOVE,& CHMNEY CAP
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 1/10/2011 0:00:00 $25.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner
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