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DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR
212 Main Street • Municipal Building �'°�., S`•y.
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNIR 108.3.4 to
act as h-is/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 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
FSttnxrTO °�?�_
of \Ia rtljctllt}tft1tt
6 �1�[SS RClt tt6Clla
DEF'l1t2TMt"•A'T OF BUILDI)�G INSPLCTIONs
212 Main Street ' Municipal Building j
Northampton, ?Hass. 01060
WORKER'S CONITENSATION INSURANCE AFFMANVIT
_v-
v"Ith a principal place of business/residence a-.
(phorlC71
do 11creby cerL1ly LI1<' :1- Ll1G' h iIl$ :'.ii7 1)Cil 1LiCS Chi pC:rlury, "Im"
I am an crnp!oyer providi11, the follov.,MC v Or'r;Cr`S C0I11pCi1SnoI1 cove["a`',e f0r trey
employees worldrig On dies job:
(I»1ranc- Corap:m,) pir:don Date)
( j I am a sole proprietor, general cc11!=c`cr hoc-,oO Der (cc,-Cle one) and hav'- 'tired
the contractors IISteC beiov.,.x110 the `Oils, .Lj Z, ttlOFke,`S GOI peII-,.2101,
('`:a_MC of COtitrlCtGC) (1115 ti.1CC LO1P.^?:i'ji1 GIIC{ ?1lISIl i) T?: r<": C'�atC)
(Name of ContT-=,or) (1.1LSlI iP.0 COmr�2;iviPohcC, Numb,--r) Date)
CNIame of Coatractor) Ins[:,Ix Coiy ;_n•;i?o!ic- Nujnr,�r) x;,sr:coa Date)
-
'Name of Cont actcr) —- (Iasi rane Come } Policy Ntlml; *) (F:xr;i�:tic- Date)
a-m a ,;Ole propTi "oi Z: ili?V 110 OI1 U?" ii` t0; DI
} I ?ill a home 0vym1 i)Ci-:0`1111I'` 11l
?i0 rl::plwsc tY I.S�Z:G t}:�:'.il;}c 4,c<:cv�ti�r_-:��-�c.-.pl�-�•;r.-::-::::n c::��:;-':�nc4 a::__n:�.:m cr:ri;air��•:;,r-;_4��c1?i',c:
not uxYe than thrco wins in ut et he f rz.;.iz -rr:,:cz C'C a; ` •:._i-�v r ee rt Lhce o c c x<Ccrrzliy cc .::::_:: :c
cmploye.3 uz.:er the wcti; c cc x-,:e:i^n Ar (Gi.15�, -! ill ^„ic:;by or p:fa:i: u.-
lep[ct�wu of as ampioyer un&er'Ln Wcvkclx oz,r.tion^.ci-
I undciztxnd th,<t a copy of th n ctatar-.cat f::..y b,fo v nfdo l to::o IYtxi t rn of Lod, triJ A4ci&n y Of —of for U.
covcrn&c veri[jt~ticc And that failure tot ,c,:�irla 25A cd MCL,152 can Icnd to the irnposilion ct r. ^i_1 pct:nl;::s
comixting of L fmj-of up to sl,5 00.00 a-d'cr -1 of::a to era}-u e'.1 civil xzuttia in tic f<,nn cf n Stc, nY.<}�' erA
fl-Mc of 5100.00 a dsy
For d r—utrsCal c ccly
1
Si zj tjrc of
S�CT01�8� COISTRUCTION SERVICES
8.1 Licensed Construction ervisor:/ Not Applicable ❑
Name of License Holder :
License Nu er
7,
Expiration Date
Signature Telephone
.�rernen Im n .a. Not Applicable ❑
r. �
Com Name Registration Number
r
AcWres Exp(at'on Date
Z2q Telephone
SEGTIOI O&,.,QRKERS' COMPENSATION 1NSgURANCE 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...... ❑
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 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
• s
IRNM GNSOF�PROP�OSED�WGRK checFc f(a lica 7e
SECTIONS,. S P
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ J Siding[ ] Other [ ]
Brief Description of Proposed Work: c�
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0 • Sheet 0
a a:e =o if on4R0 ex sting
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
EC O lAf ER�U FlOiRIZATION TO BE COMPLETED:VVIff
MI
O 'N�ER � O ONTR�ACTOR APPLIES FOR BUfLDING PERMIT.
I, S� <� P�� r ' '✓ ( as Owner of the subject property
hereby authorize to act on
my behalf, in all matt s r lative;ty,%oWauthorized by this .building permit applicatio .
Signature Ow Date
I, 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
Si ature f 0 ner& Date
Po- %
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 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 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:
jolnrO
Northampton
g Department
Main Street
oom 100
pton, MA 01060
240 Fax 413-587-1272
DEpi Or B
ION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE IN,FORMAT10N
This sectio"#o Li`" mp,Fete° �byffic k
1.1 Property Address: �3
ON
R
1-11a a ' Q 1 6
EIm�St�Dist'nct CB Discf ... _.:
SECTION 2- PROPERTY OWNERSHI_P/AUTHORIZED AGENT
2.1 Owner of Record:
%mac
Name(Print) Current Mailing Address/ g
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION'3.- ESTI MATED CONSTRUCTION_COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by ermit applicant
1. Building ,. (a) Building Permit Fee
2. Elea rical (b) Estimated Total,Cost of
Construction,from :5
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection OQ
6. Total =(1 + 2 + 3 + 4 + 5) Check Number
This
` Section For Official Use Only
BuildingPermif Number: - fSl�� ld / Date Issued;
Sagnafure:
Building Commissioner/laspector-of Buildings Date
r
File#BP-2b04-0104
APPLICANT/CONTACT PERSON Ronald Mistarka
ADDRESS/PHONE P O Box 205 (413)575-1271
PROPERTY LOCATION 80 DEERFIELD DR
MAP 29 PARCEL 169 001 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 7,270 A SO
Typeof Construction: REPAIR SILLS&PLY
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 069836
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO
ATION 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
Signature of Building Offi ' C41 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.
BP-2004-0104
i a <X
GIS#: COMMONWEALTH OF MASSACHUSETTS
`29=t69 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0104
Project# JS-2004-0168
Est.Cost: $7000.00
Fee:$50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Ronald Mistarka 069836
Lot Size(sq.ft.): 32931.36 Owner: BRACKETT STEPHEN J&KAREN A
Zoning.URA Applicant: Ronald Mistarka
AT. 80 DEERFIELD DR
Applicant Address: Phone: Insurance:
P 0 Box 205 (413) 575-1271
NORTHAMPTON MAO 1061 ISSUED ON:814103 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR SILLS & PLY
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 Sienature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 8/4/03 0:00:00 1489 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo