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35-059 O¢'CtSA1NP�O Cr%iflr of Xart4ainpton L 9 � �Trlassachusetfs DEPARTMENT OF BUILDING INSPECTIONS /= INSPECTOR 212 Main Street • Municipal Building ' Nortlivnpuon, MA 01060 r HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to act as 1-1is/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 f Fro oy� 0rL2�� t7f ��nzrfll�llt}�to)) _ �;i3i RCh RLrttO- -- p DEPARTMEITT OP DUILDF)\,C INSPECTIONs 212 Main Street Municipal Building Northampton, Mass- OIOGO 1, WOMCER'S COIVM , NSA'nON MSUTZANCE AI— Avl-I' j 01 MTsxlpermj ttcc) h�th a principal plat- of business/residencc at: / l caty/s==lap) do hereby certifj under tt)c.pains and penalties of per7ury; hai ( ) I am an employer providing the followinL worker's compensator, coverage 'or In) e1 1 ve v o Ls _ -n orki on ti i- - p $ > a lob. i j - (Insun-s= Comr_cy) (Policy Numbcr) -- (z=;-pirztiorr Dam) 01� am a sole proprieror, eoeral contractor or homeoitiner (cu c:e one) and have hued the cooua(nors listed below who hive the following worker's compep_sp-bon policies: (Namc Oi CQ9r^ci0r) Onsurzncc Co1nm i)-Pt o6c NUIIlt<:) t tiptid ^? D iC) i j ` (N one of Coomaor) (Insurzncc Compan}vPo!ic \uncfr) (-T:x-Dii7-don Dare) i (Name of Conao,) Ozsurancc Compan)•/Pouq- Number) (E�piraeo Date) na (Name of Coommor) (Insufa.acc- Company/PaLcy Numbcr) (Eapifmion Daic). (atu.c�_ddi�ocaJ rScct.if acoca�•to mots&iafor=a Eoc pQrtx-inias to all cots--mon) ( I am a sole proprietor and bave no one working for me. ( ) I am.a. home owner perforrni-ng all the work myself- NOTE:plesc be aw-Ar<t4.,•�{ rc bcc ec .,,u•bo=mplcy PAD to� .i, - �;e�oo c rc,;air work on t d.. U-nZ of in the homoownrr r=d.or oa the pMunca,�pstte•n_rs t6een art ooc Coe-_U-y oee=:dani to be cz=ploye s uar a the�.ui dz ocr uon Act(GLI5Z=1(5)),apptiapon try a bammavc fcr c be.--cc pa=n r=y c%4denoc the jIc-PI n-,..of d-Wwkorc C...p lioa filet_ t.+adazuad dLd a copy of dl ix may bd f---,i-d to Lb.Dopor mmc of Indusric!AcvdcsU'OM—of Gs ooe for tb. oovmtsc�cif.•eslioa a_'sd Ilt:1 L-iltzc Lo sonuc E'AVCT t tmdcs soclioo 25A of MGL 152 na lQ d to the im,osaioa of Qimiai!pea&ltia oomtrin of i rtnc orup to S 1}00.00 andlor i=x-ttioom orup to ooc year rod air pm-.kj..tSc focm of a Stop Work Or-d,and a Fi>b of S I W.W a d_y Lr mast mG -- For dyy1 u.e only -- Permit Nt1ML--r i,�apw Lot n si tier of Lic=salpermiucc —T33Ce J SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: / Not Applicable ❑ Name of License Holder / License Number RC/- U. 11647 A- dd ss Expiration Date Signat Telephone 9_]2eg..rstere'�;H s ,.n Not Applicable _❑ �acO& U � �am Company . Regnistration Number e//any L-/dt&e /Jz/-l� �G' ��✓nillC%�.. K?� /fll�a ©I�� �t ``y _ n `�' Address M Expiration Date Telephone JoC 9'GL1 dC7 SECTION 10-WORKERS'COMPENSATION INSURANCEAFFIDAVIT(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...... ❑ 1` � ll '4'TLlC" 0"NAM 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 OF PROPOSED WORK(check all applicable) New House ED Addition E] Replacement Windows Alteration(s) ❑ Roofing ED Or Doors Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [C7 Siding[Xi] Other[a Brief Description of Proposed - w aus Work: PW << n 'n/C S ��_ r t ih /hJU& eo' /nip uAlm, Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet sa:�l��ev�Fionse a�°d-or.a` " difiolr�rtcY�ex>ISting.t>iousin�t :cflrnptef���r� o'F�oW�n4: 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.-=OWNERAUTHORI7ATION--TO BE'COMPLETED:WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR-BUILDING PERMIT as Owner of the subject property hereby authorize 'w Urlfi/! e kl'po(�C�%� to act on my behalf, in all matters relative to w6rk authorized by this belildIng permit application. Iv 2oo� Signature of Owner ate as 6arw/Authorized Agent here eclare 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. s Print Name Signature o rmgent Date ' ' ' Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information Existing Proposed Required by Zoning This column to be filled in by Building Department Lot Size Frontage Setbacks Front Side L. Rear Building Height Bldg. Square Footage -------- % Open Space Footage % (Lot area minus bldg&paved #of Parking Spaces (volume&Location) A. Has o Special Perm it/Vuhonoe/Findi ever been issued for/on the site? �� NO \~��� DONTKNOVV �5� YES �� IF YES, data issued: IF YES: Was the permit recorded ot the Registry ofDeeds? ' �� NO �� DON7KNOVV 0 YES IF YES: enter Book | Page and/or Document#' ' L_______� ' �� �� �� B. Does the site contain o brnob, body of water or wetlands? NO �_� DONT KNOW x�� YES �_� IF YES, has permit been or need to be obtained from the Conservation Commission? Needs tobambtoinad Qbtaioed �~� Date\_� ' C. Dn any signs exist on the prnperty �� ��� YES �°� 0O x_� 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 YES, describe size, type and location: E. Will the construction activity disturb(clearing,grading,excavation,nr filling)over 1 acre oxiod part ofo common plan that will disturb over 1 acre? YES NO ��� � |F YES,then a Northampton Storm Water Management Permit from the DPW iorequired. ` 1"� of Northampton(ding Department12 Main Street 2Room 100 JUN N ampton, MA 01060 phone 41�-587 1240 Fax 413-587-1272 l APPLICATION TO-GOWSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING I SECTION 1 -SITE INFORMATION This section to be comple#ed by efface 1.1 ProgertV Address: Uftl Zone _ OueriaY Drstc�ef Eicta St Dstrrct C6 DltF�cY �. SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED-AGENT 2.1 Owner of Reco rd:/ ,,// / 9 Zck&hct� gd. Name(Print) Current Ma Ii Address: Telephone Signature 2.2 Authorized Agent: 0 r �r Name not) ,Current Mailing Address:-7, } Signature Telephone SECTION-1-ESTIMATED CONSTRUCTION;:COSTS Item Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building 4(6)Bullding.Permit Fee 2. Electrical �(c,[ Q / 4b)zstimated`T.otal 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 Commissioner/Inspector of Buildings Date NNW BP-2006-1396 GIs#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category BUILDING PERMIT Permit# BP-2006-1396 Project# JS-2006-2070 Est. Cost: $22813.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Groin TIMOTHY SKROCKI 117441 Lot Size(sq. ft.): 66211.20 Owner: HUBBARD WILLIAM B& SANDRA S Zoning: SR Applicant. TIMOTHY SKROCKI AT. 932 RYAN RD Applicant Address: Phone: Insurance: 81 LAUREL HILL RD (413) 529-0527 WESTHAMPTON MAO 1027 ISSUED ON:612612006 0:00:00 TO PERFORM THE FOLLOWING WORK.-INSTALL NEW 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: FeeType: Date Paid: Amount: Building 6/26/2006 0:00:00 $25.002483 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo