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29-259 pQ'��MpTO (r ifV of Wart4a ptan L r 7t C J �i[55AChliSttt6 DEPARTMENT OF BUILDI7\TG INSPECTIONS /= t 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 his/her construction super,, sor. 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 'dress of work on Y O C1'zftt z1f ct� tlj�tlll}�t>ilt _ ' � ,. 6 �iltssacFJttsctts 1)E11 AIRD,fE-N.-F of DUIIDING INSPECTIONS 212 Main Street ' Municipal Building j INTorthainpton, Mass. 01060 WORYCEIR'S COMPENSATION INSURANCE kFFD)AVIT "" th a principal place of bus I]essJr, :Sidenc� I: :" C 0 0 b P--c I 1 — � Y7 ---- do her(Joy CertlI}t, t:l):" r tllc -,P�lns aid 1)Ci]?tt!CS OI pF;r311 Iy, lha,, ( ) a-m an employer providil1- the fbllo',V1I1f- . or;cr s C0ll1T)C;1SZ 10I] GO`'C17:vC FOr illy employces working on this job: (InslranG Colnpam') Nu-lbcr) --- (rte cir don Date) j 1 am a sole proprietor, glen°rat con�:rac cr hon:eo'.Vve: (c cle 03t) and 'gave hired t-li,- Contractors llsted be:ow Vi l]0 iii. t17. . `OIIC ,'vu: VOrke"s COu pens-a' oi! (T:=c of Contractor) (1n5)=.-.,1C l oII?^?;)r'il G ICf tL13Il i) T? iC' Datc) (Name of Conic cto:) (Jns-dr nce Cor fc, ,rPG!ic,' Nun-trr) (I xGir.:tioD Daie) (Name of Contractor) u:tir:T; uo7, DatP.) - (Name of Contactor) _ (Itis�r�I]c Comr ]y i olio ititirmr..r) (I%:pi�:ao Date) (^It.ICI_`.d�3::CYM1f S;�Yt:..._.... ::�..r_.......�...:Y::;f..�Y:,._..-.... � all�_f:��..-•..'� ( � 1 tLll rl SO1C l?rGl?:1CtUC 2 :'1 h�?VC ilo OI1C „'�;Chii`; 1.Or ilie. I ;,m a home Ov1T1er iiOi:C1"I?11I? 1l( i!: NO-rfi:plc�sc tc nt.-a:c tl;a;:��•iIc I'rt<;coazr_;s:��-�c;_.�1.��;rr.-:-::n c:>���-'::a.�c:,a>:c_:,:C:m cr::r;ait�^;;;'�_�•'c!!i'-�°.. not mcce thn[hrot units in t:i idt*-hc cn cx;'` _-..z z -_r cr_nI'hcc c a c ox Gcxr�l!y :o t� czaployc-3 u_ti�s the woci'•ez.ca xc:a:irn Fr ((iL!52�s i(Sr,a,: ._:;ia; y a hotnco:c-rf for n Lccu a legal etantc of an=Mployor under tL•o Wcvicc�,f CocLrxr iiior.!.cL I undc-s;..nd di..i a cmy of thi, ctatci-s_•my bo foax-loci to tlr[YtiarLZxn:of Ictidi3.s;ri_1 Aciir.�t��%{�c`O°f '='``r`'"''-0 for i!x cov=&C vcrificz&a a,.ul the t f_ilurc to;-;c-;r_crop r ur cC.iM 25A of?.tGI.152 can it--d to U-impasiiia of r i 1 pa:all:cs comisii rg of a Cur_of up to S 1-500.0`)e: 'rf i-::nrixr. :-r o111 p to c.r.-)-t r.-.I civil pau1 C.1 in do I<nn cf a Stc•,,`.i' e:d a Lrzr of S10G.t?0 i dsy tgium1 m.- . --------------- � (v/P3`'� FF,fyr3•uuzrstal u.°on!y. Z �. Permit N,11I11)1= 51va1 C t)1• r Tj:is ,.ICCIl';Cc_/�iCCllliitCG r SECTJ0N 8 CONSTRUCTION SERVICES' 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date e�- Y-7 Signature Telephone .L/ i �Re"°" sf�e° °e 'ome m'arose ent CoC ntr ' 4 Not Applicable ❑ Company Name Registration Number I Dy ( '�>3 Address Expiration Da Telephone a SECTION i0 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 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 SECTJOi� b1`S .;fPTONOFPROPOSED WORK checktl a'OP laca�te New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding Other [ ] Brief Description of Proposed Work: V r Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative D Renovating unfinished basement Yes No Plans Attached Roll D- Sheet D 6a if e .ouse—nd o addi tion.>to`7ez.istljojt using c ftre et he`ffoilowrng: 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["7 WNER U HO .;T BE°COMPLETED RI4Aff0N " WHEN OWNERSA�ENT OR�COITRACTOR APPLIES FO,R BUILDING PERMIT' C 7S / ��1 5/C/ as Owner of the subject property hereby authorize _ �� (� �,i .�SIc/ to acT on `behalf, in all matters relative to work authorized by this building permit application. Signa re of Owner Date as Gw=/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 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 DONT 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: 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 IJ�OE tlf DWELLING ij"r 'IT SECTION I-SITE INFORMATION y Th�scfiogto mplete±3 by office 1.1 Property Address: �_ , � �� x fir„- t 2--7 L c-©K Zone OveHay District d(Q 2- Qin$'St,District " . ._. cB��stnct SECTION 2-PROPERTY OWNERSHIPjAUTHORIZED AGENT ' 2.1 Owner of Record: "1-3 JA-ME5 L ,�1C l27 �elc, bK Name(Print) Current Mailing Address: Z. n F2?Jrc �`'�- Telephone 7- Signature �.3 5-8 J 2.2 Authorized Agent: Name(Print) Current Mailing Address: �f13 ) I 7 1d1Li • cam V13 31 �a Signature Telephone SECTION ESTIMATED ONSTRUCTION COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit appli cant 1. Building , o ry .(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) DD °� Check Number This Section For Official Use Onl Building Permit Number: Date Issued: Signature: Building Commissioner/Inspector of Buildings Date 127 OVERLOOK DR BP-2004-1061 GIs#: COMMONWEALTH OF MASSACHUSETTS Map-.Block:29-259 CITY OF NORTHAMPTON Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: BUILDING PERMIT Permit# BP-2004-1061 Project# JS-2004-1585 Est.Cost: $1200.00 Fee: $25.00 PERMISSION.IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Groin: John Zieminski_ 100133 Lot Size(sq. ft.): 15028.20 Owner: ZIEMINSKI JAMES Zoning:URA Applicant: John Zieminski AT: 127 OVERLOOK DR Applicant Address: Phone: Insurance: 8 WOODRIDGE CIRC (413) 247-9014 Workers Compensation HATFIELDMA01038 ISSUED ON:4130104 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL VINYL SIDING 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 4/30/04 0:00:00 1544 $25.00 212 Main Street,Phone(413)587-1240,Fax:(413)587-1272 Building Commissioner-Anthony Patillo