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�111855AC(�llSttt4
's" cs DEPARTMENT OF BUILDING INSPECJTIONS /: ^
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as iris/her construction sup( : .,isor. 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 buildinL 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
11 - , 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
, J
pTO �
dill of C'rillampioll
6 11l t 15 A Cll IIS Ctl 1
DEPARTMENT OF El UIL)NG INSPECTIONS
212 Main Street ' Municipal Building j
Northampton, Mass. 01060
WOPJCGR'S CO-MTENSAUON INSURANCE A-FFMA IT
%vlth a principal place of busUao-ssJrc>ie<.ne
ClO �1CICby CCI LI�'; tlti;lcl" L}1C T ills ,'.nd peil:it_iC._ Oi ��f:�llll+ T.Ill+.i.
am zui employer providing tlic i0�10'.vil:1, '•'.Oi'::Ci`S COII�pCIIS UOD GO``C:2' C fU` :I�}'
emplovices working on tills job:
jns' nc--� Company) i c c.Nti ber) (E,.;,iraon Date)
t ) I am a sole proDrlctor, g'tntFal ccnt7a(7ior hoTneo`:vDer (CliCIC One) aIId Cared
th'-1 contractors listed beio'v-�vh o the �,.,oFkcrs coan.pen-sa-on po?i—s:
( :CSDC Of COntSlCiGr) �P. 'C^.1C l CIII^".;7'i Gllc l NUI7tCi) Datc)
(Nz-me of Contrac"Or) _ ±�ltsar, rce Ccm�_.I�'Pc1ic; \tr7rr r; (Ey: :ration Datej
(Name of Con:;-actor) (Inscr-mcc (_:qty;anvii'ol.c: Nuln}xr) -.x; rr:noa Date)
- (Name of Conr — 1 c7, Date)}
l
l 1 Zuni a SOIL proplc"")i :ii- K?':'C 110 =)E'
-) Hill L? home 01%`17?1^:
NO'D:: lccsc tic twzrc LEI''.vL:l 1;ry;>—:c t�;t .^_x n_ cZ:::_n m or
1. ;JC IX±rGUt\l Y_t1��TrJ G'a� •• r•-
not:lice tli n t2 roc uui�i: z' ei Lhe 1ti.-. ..lz,-r 3 c.•oc;'`
crtployc3 utidxr 1}so tvc:?,_i s cc -_>a:i^c z (<,:.IS2 t(Si.,a,:, :icn:ryJi hotnco�• ,r `:cr a b� cc
legal C-' tux of an a-.nployor under tLn wo icclz Con^,m ati m!.ct
I unde.--stn d the a e'my of t}v etatc;:s_•nuy ho tln Aoc .�!y C'frio of i:::+_rr for lje
cove vc-j'c_Iioc a:ui thst C_ilurc to t_as: :cc.ic.2 S A of MC-L,152 a.n[r---d to tlx imposition
coc=i.TtLng of a fur_of up to S 1.500.00 n:�-'Y of:!p to cr.y r.-.j evil xnxltia in do fcnn of a S!r,,V:c z(h _:.:1 a
ram of:,100.00 a d-ly z gn_itnl m:.
._ /� 1=cX�;uvta�stsl u�c uily i
T f
Ji ;vnturc c)t I.iCC71f C J1 S n1 ittCC.
SECTfON 8 CONST,RUCTIQN SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
.1j
Address Expiration Date
Signature Telephone
� Regiseed°' brnelm'a vro emerY`'Contr`acto'r = ; Not Applicable ❑
Company
Name �— Registration Number
Address Expirati n Date
-Telephone—A,
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.......,,2r' 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 acecptable to the Building Official,that he/she shall be
responsible for all such work performed under the buildine 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 _!/`�
SECTti0N5. DESSP�TtONOFPROPOSED WORK(checkll appl�cai� �
. a
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Deck
Siding[ ] Other [ ]
Brief Description of Proposed Work: C__ �
Alteration of existing bedroom Yes_� No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes _'Z No
Plans Attached Roll❑- Sheet D
!a57F New= ouse and or addition to existing'Frous"ing�comp`tef`e"° tT�e follow�n
a. Use of building : One Family t Two Family Other
b. Number of rooms in each fame idly Qunit: 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? 9C"4, 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 ✓f
SECT10N�7aOINNER Al7THORIZATION TO BE'COMPLETED :WHEN
OWNEf{S i4GENT�ORjCONTRACTOR APPLIES FOR BUIt:pING PERMIT::
I' as Owner of the subject property
hereby authorize ��Ack' to act on
my behal , njall matters relative tO o k authorized by this building permit application.
(l Jl LPL L I
Signature f Owner Date
I, %41C ' L}j L (QA-:-
3 3�A k ` 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 j
Signature o ,Ow er/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 /?� �� -
� i
Frontage
Setbacks Front
3S
Side L: 1 Z R: t L: R: S
Rear
Building Height {-
SI
Bldg. Square Footage //DID %
Open Space Footage %
(Lot area minus bldg&paved
arkin )
#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 DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ✓ DONT 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:
- i�, �"
IN
City of Northampton ;
Building Department
212 Main Street
Room 100 '
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE-INFORM ATION _7
1.1 Proae ft Address:
T(us sect�o�x 0"' e completed by office
`/-'' .L `�� �---t t✓(_, `.�-1�_ 16 ET
/v `� Zone O�rerlay D�stncE
�St�D�stnct°. _.n;CB D�s6ct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
N�Y_l + ICS- t L C _e Y-) i r�
Name(Print) i Current Mailing Address:
Telephone Ir '
Signature `—t
2.2 Authorized Agent:
Name(Print) j ' Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION'COM
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit 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 t 5) -- 'y Check Number `
This Section For Offidial Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
1Ar s
File#BP-2004-0992
APPLICANT/CONTACT PERSON LASTOWSKI RICHARD E&CHRISTIN
ADDRESS/PHONE 92 SANDY HILL RD FLORENCE
PROPERTY LOCATION 92 SANDY HILL RD
MAP 29 PARCEL 398 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: ROOF FRENCH DOORS INSTALL DECK AND RAILS
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
INF9RMATION 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 Co ssion
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.
92 SANDY HILL RD BP-2004-0992
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-398 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categor: BUILDING PERMIT
Permit# BP-2004-0992
Project# JS-2004-1466
Est. Cost: $0.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: MICHAEL MOORE 077024
Lot Size(sq_ft.): 11020.68 Owner: LASTOWSKI RICHARD E&CHRISTIN
Zoning.URA Applicant: MICHAEL MOORE
AT. 92 SANDY HILL RD
Applicant Address: Phone: Insurance:
P O BOX 5942 (413) 782-3200 Workers
Compensation
SPRINGFIELDMA01101 ISSUED ON:4128104 0:00:00
TO PERFORM THE FOLLOWING WORK.-ROOF FRENCH DOORS INSTALL DECK AND RAILS
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 Occupangy Occupancy Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 4/28/04 0:00:00 6707 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo