35-045 (2) O¢�t1/V�lP�O
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DEPARTMENT OF BUILDITjG INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building
Northampton,MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as 1-11s/her construction sup,:: , 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 f egulations. 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
de
I, y understand the above.
(Home owner/resident's signat a req esting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
r
i
�o
0
(rii� of �Inrfllallt}�ton _ _—�=
Q DEPARTMEIJT OP DUILDr?.\,G INSPeCrlol.'S -
j 212 Alain Street ' Municipal Budding —
i
Northampton, glass. 01060
W01UG:R'S CONUENSA`I`zON LNSURANCE AFFMAVI-1-
I .
(Ii ctnsxl perm�ttcc)
\V1 Lb a principal place of business residence at: - --- --
— (phone')
(sar�t/c�ty/szatc�a p)
do hereby certify, under the.pa_int and penalties of perjury, :hat
( ) I am an employer providing dic followine'worl:cr's comocnsado, covem"c for lny
etuplovees wor>ong on Lhis job:
(Ianu-� Con mr) (Pclic-, Nu-7i Dcr) --- (r YD7rcdOri Da=) -
( ) I am a sole proprietor, general contractor or homeowner(ci cie one) and have hired
the cooua(nors listed below wi;o have the 'oUo�v*n workeris co0oen-aaon po!icies:
(i+SII1C Oi COnr^Ci0') (Ir1R1r3IIcc C011103n)•/Ilobc' N'LLMtG) Jt3J:_Q Dalc)
- (Namc of Coacrzmor) Ms franc: Comoaz"'Rolic- Nt:_mcrr) (E»irz6on Date)
(Name of Coumclo.-) (lnsurane C=Tia.n)f%Uc}- Naslu) (ExpLim600 Date)
(Name of Contractor) (Lasurancc Compazy/Poucy Numb r) (Expirdtioo D'art).
(aaa.cjl.,t�:�oc=.I�ca.ifnccc.{�•w a"c,sd=iaf'«rs._zon
{ ) I am a sole proprietor and have no one working for me.
I am.a home owner performing all the work myself.
NOTE:Plesc ix Ltrut t*,•..{ lehemr Hers.�•bo emPtay P--Lc=w do myau u-orz on a d.•Tr -z or
i
apt m«z t!»t L^.1tJ is t{��t ttX u�+il.,_., 7=d�,IX cc Lb.-p= in 6 i7pu r ts'd.D LT oo(C—__—I y CCC:U-26 to be
eiipioye-�unL,-the., kx,�':a=pc=.:-ociAj;x GL'I52=1 S
t ( )�:.pplicuioo 6y a hommaaa fc:tip.«Pc:nu cry{,idmcc the
of=c=:ployw u.dor do W orir.ora CooaPomal io o Act
[—d—L-id tha a copy orthi.c—acal m„y bo ro- ordsd to ti, Bctx,lmm:ort use Aid Offou or4aur+oou ro(t6o
covcfl- waif(=tioo'�ltLt � �'�`KTabc undo 3 xtion 23 A er MGL 131 eta I=d to the i=palidoa of aimiait Pazaltie
ooa:i mg o(a rtoe ortp to S 1 Soo.00{nd/or jjn po orup to oo yr3r Lod all Povlja s 6e ro[m or slop wo
ri h Ord--aid{
m of S 100.00{dsy{p-iast(Or-
.—only
Pctmit Ntrmbcl
i rt
1'42 P."—_ Lot x.
StpyZ�nofLi�ct:/Pcratiucc L�ir �e -- -� �.
SECTION 8-CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
`
m� ' . ry - _ Not Applicable ❑
9'Reiiisfereil`H'orrie lmara�er'nent Conrtractor
Company Name Registration umber -- -—
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 =�ompWnelrrg4�a
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
No hampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
omeowner Signature
r
SECTION 5-DESCRIPTION OF PROPOSED W..ORK(check'ail applicable)
New House ❑ Addition Replacement Windows Alterations) ❑ Roofing
Or Doors Cl
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [M Siding[0] Other[0]
ief Descrip of Pr posed
){�
Work: -r – ./ lam/4L U �� aZ—, A l eA i
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa Cf New.iiouse ardor_acid ncr ous nct.:comL3iet"6e 1 ifoftQW nc:
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
I, 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, 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 ame
Signature of Owner/Agent CIO, Date
,
'
. ,
Section 4. ZONING All Informati6h Must Be Completed.Permit Can Be Denied Due To Incomplete Information
4 Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
'
A. Has a Special Perm it/Vahanco/Findi ng ever been issued for/on the site?
'
NO 0 DON'T KNOW 0 YES 0 �
IF YES, data issued:' {
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 0ON7KNOVV 0 YES
IF YES: enter Book Page, and/or Document# |
B. Does the site contain o brook, body of water orwetlands? NO 0 DON'T KNOW 0 YES 0
IF YES, has a permit been or need to bo obtained from the Conservation Commission?
'
Needs to be obtained x�� O��o�mmd ^~-� Date
�~� v_� '
�� ��
C. Do any signs exist on the propor� ��/� 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 0 NO 0
IF YE5, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,nr filling)over 1 acre nrisd part ofo common plan
that will disturb over 1 oonn? YEG � .~,K ) N� � )
~~�
/
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
y
---.----.—"City of Norte ampton
It{ding Departments waPertt ;
- -- T 2 Main Street sew rye trairabi[� �
j I Room 100 t♦1 afe�/fltleiArratit
- Nmpton; MA 01060 T ��etso truSctrrafPtaris
phone 4 o -1240 Fax 413-587-1272 Ptot�Sit�1l�Ians
k
APPL1CAT1ON. -`. NSTRU T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This.section to be complete by office
1
Property�Address:
A0 Zorr7;1<
ie Overlay�FStnc#s
Elri Sf District CB Disfrict °
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Current Marlin d ress•
T -Q26 2;�
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 ermit applicant
ng (a)Building Permit Fee
0
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
This Section For Official Use Only
Date,
Building'Permit Number Issued:
Signature:
Building Commissionerlinspectorof Buildings- Date
967 RYAN RD BP-2005-0358
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35-045 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-2005-0358
Project# JS-2005-0477
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.8.1: 31842.36 Owner: SLEZEK EDWARD M
Zoning: RR Applicant: SLEZEK EDWARD M
AT. 967 RYAN RD
Applicant Address: Phone: Insurance:
967 RYAN RD (413) 586-2677 0
FLORENCEMA01062 ISSUED ON.9128104 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE ROOF
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• Receipt No: Date Paid: Check No: Amount:
Building 9/28/04 0:00:00 1215 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo