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DEPARTMENT OP BUILDfI\)C INSPECTIONS
212 Main Street ' Municipal Building
Northampton, Mass. 01060
�V O IZ1CI I Z'S C O ATP E N S A TI O N M S UIZA, CE A I F M A VII
(li ccus.cc/perm�flee)
\vIth a pi-,-tcipal place of businessfresidencc at:
(phoney') -
--- (SO=Vcity/siam/zip)
do hereby certifj;, under the pawls and penalties of perjury, ihal
( ) 1 am an employer providin- die followine work-er s comoens-n�jon cove gc for In),
etuplovecs Nvorkang on this job.
OD=n Zcc Coor'Lov) (Polio; Nu_abcr) -- ( :"pir-,Uon Date) "
( ) I am a sole proprietor, general contractor or homeowner (circle or!e) and hwe hired
the contractors hsted below who have the foOoWvinQ workeF's C-ODJe1152UOII policies:
('NaIDe of C on.[r?cio') (1r1-umncC Coinpa7l)'rPGUc'{ ?hum'-Q)
(Name of Contractor) -- (Las-d=cr Comanv/Policy Numcsr) (Expir Lion Date)
(Name of Contramo;) Qn_surancc Compan y/Pokey' Numb:r) (ExpLm600 Datc)
(Name of Contractor) (I.nsufance Company/Policy Numb=s) ( x-pir-o6on Date)
(anach OCil t!>cc1 if ncOa ry to oc ecru nins to all
O I am a sole proprietor and have no one worn-og for me.
am a home owner performing all the work myself.
NOTE:PI—c be enarc t},..w'f_Jc boarOWDC"ubo aap(oy peraoa to dZ c^ �,-+ _c .^.:c�x�c re v�•'orK oa.d.�ct1= of
ant most than t�,--tmro in winch the L moo-.m do or oa the p-ouartt:Pputteau-tse- LT we C="k=ally oco:dxil to be
eatploycs unGc Lhc t.�i L{=amts Lm Aril(GL1 S7 Q 1(5)),nppUci6oa try a homeow=far c l ca v_a Pomit rn y«�dmcc he
IcvJ nnau of en cgloyer under dio Wocic.o(t Coa*oaoatioa e, L
I uodcnand dLd a copy of 16i,m.f--w m.y be for-xry Ied to tbo Dopertmca[of Ln iu✓id Al &-a&Ofr) o of(taut=nw for tl�
oovQ t se yeti[e4ioo aid ttu Lirtat to smuc bovciage tn�dcr section 25 A of 11oL 151 cac Lmd to the=PoS6on of uAMiwd pcOsW-
0003L�of a fioc of up to s l-500-oo anNor of up to ooc yczr end aril paul-un tr LS form of a Stop Work Order"rid a
rim 0(5 1 DO.00 a day afaiwa me
For dN.rtn'��u-only
Pcrmll NLLmbcr
Lot
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DEPARTMENT OF BUILDrItG INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northamptcm,MA 01060
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. 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),
s_onotube holes (before pour), a rough building inspection (before work is
concealed), insulation inspection (if required) an&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. . Ic ' understand the above.11
(Home owner/resident' gnature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date 7 J
Address of work
location
s
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0,"'
Marng of Ucenso H I
license Number
-- -- --------------
Ad�ess
Expiration Date
-------------------------------------------------------
Signature Telephone
9.Registered Hom Imnroverrfent Contractor_ Not Applicable 111�-
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
SECTION 5-DESCRIPTION QF.PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ __JZofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[If Other[ I
Brief Description of Pr psad
Work:- V I'M�/. S I D//✓�
Alteration of existing bedroom_-_—_Yes No Adding new bedroom_______Yes —_—_No
Attached Narrative Renovating unfinished basement _ _Yes __—---No
Plans Attached Roll -Sheet
sa.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. 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___--
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
-- -- --- ----------------
prop rty
hereby authorize _ _ _ _ _ _----------------------
to act on my behalf,in all matters relative to work authorized by this building permit application. —
---- ------------------- ��------------------------------
Signature of Owner Date
I,- �S�' _ T ,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
---------------- ----- ------
-7
-- ---- -- -------------------------------------- -------
Signature of Owner/Agent Date
r
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 V' 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:
Depeatnop
City of Northampton e�f unit
Building DepartmentDrily Pmt
212 Main Street illy.
Room 100 Watelly .
Northampton, MA 01060 7'w�a: tt�frs
phone 413-587-1240 Fax 413-587-1272
Spy.
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
Map_--__—_— Lot
UNP-Vl EW PdC- fLd g ANC e Zone-----_----Overlay District__--
Elm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(P'nt) - — Current Mair�g pd
• - s '-dr
---
�1��_—Gu ---------------- Telephone
Signature
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 rmit applicant
1. Building �)O�U�U (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=0 +2+3+4+5) Check Number
This Section For Official Use Only
Building Permit Number.—__ _---__--_— Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
r BP-2004-0043
x r,
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot -001
Permit: Buildina
Category: BUILDING PERMIT
Permit# BP-2004-0043
Project# IS-2004-0076
Est. Cost: $2000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 15333.12 Owner: KUZMESKI MICHAEL G&SUSAN J
Zoning URA Applicant: KUZMESKI MICHAEL G & SUSAN I
AT. 57 LONGVIEW DR
Applicant Address: Phone: Insurance:
57 LONGVIEW DR (413) 584-7816 0
FLORENCEMA01062 ISSUED ON.7114103 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 Signature:
Feel e: Receipt No: Date Paid: Check No: Amount:
Building 7/14/03 0:00:00 139 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo