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Crxty of Xort4anzpton L z
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DEPARTMENT OF BUILDINTG INSPECTIONS f:
INSPECTOR 212 Main Street • Municipal Building
NortliamBton,MA 01060
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sup„., sor. T he state defines"Homeowner” as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fami
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
m de
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
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F E CritI of �'To -tIjullipto11 -
. �1a�anrfJnsrlle'
DEPARTMENT OP DUILDr-,1,10 IOSPPCTIOI.'S
212 Main Strcet • Ifunicipal Dudding
Northampton, Mass. 01060
I
WO RtQ l *S C O iAP EN S!I'I'I O N M S URA CE A FFII�
(li=-C cxJpermI tfCC)
t.�th a ptz-lcipal place of business/residence at: -
j (phone')
(SC-�z/ci ty/stal-lap)
do hereby certify, under the.pain_s and penalties of perjury, :hat
( ) I am an employer providing t11e followIM-1 XvoncCr's COlnocns-n:Jon cove-'se for Im
e113pIOVCCS v,'O1iong on ties job:
i
(Iasi.---n=Conn:m') (Polio: Numb r) -- (r;'piruor. Dom)
( ) I am a sole proprctor, general conu-aaor or homeow-oer (c cie one) and hive hired
the Consaciprs listed below who have the following workers caLoen_s26on policies:
i
(Nam-' o;Co tncaor) (InR!ranc. Comoan)-/Il ouc; D.11c)
(Name of Coocaaor) (LIs -auc-. COMOanvipol m Nujlc�:r) (F.»ir:oon Date)
I
i
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(Name of Connacio,) (Insuraucz ampan}'/Pone}- Namb,-s) (Expirrioo Daic)
(Na-MC of Coatraclor) (Las'UmnCy ComraUYIPoncy Numb-`-) (Eaptrtloa Datc).
I
(nnsc3� ri!rirw_1�c�.ilncoo.-y w a �uc�iafc =AZiOC pctaiains to.0
O I
am 'a sore proprietor and bave no one worhdDg for me.
I atn.a home owner perfon=g all the work myself.
/
NOTE:L:PICSC be LW-Art U:Mjijo bcc)cc" SS Kt QVtQy Lo do = c=r-,a Ioa C ii73d work on t d-,UI=,of
oat mcrc tb a `tso tmt r is t-b;cb the bomoowner t caido a oa the pma Z,6>aputtta tSccI r_-r Dot > .11y oecdaai w tr
I eixployea un�c the wcci c�=c-.,,o.Aa(GU452ss 1(5)�=pplicL.000 by a bomeoaaa for-lies.or pcmit nay--rd—tl c
Ic-Su rt="of nn c=ployx under ttro Wockce,Co�on Act_
I
[uadQnaad th.2 a Dopy of lhi.catcmcm ov.y be foc-MV dsd to tbo p.cputmma of lndusricl A—&-W'015—of ttsvr.nc++for the
eove►b'e vciLelioo nod thst L-LM to so=M teovcr LCC tuck soeiion 23 A of h(OL 151 m ImZ to the iorposkioa of a imiasl pcualtie
eoaztLSttg
or t fmc orup to s 1 Sto,00 aioc,,6apr6oa=C=oCup to Doc yr=r end a%il pmahim io tSc form of a Stop Work Orde nad a -
rim O(SIDOM r day rpin:9 tnc
For
l - Pcrmtt NumL--
i
Lot"
Signs of Li
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SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
„_; .... ., -,...- V i"� zktiE'R,°. �ygn '•'a3!�Yr *(W r ... __
9e $eretoin�e m �rerner► Contraco"-. $ . Not Applicable ❑
Company Name ` Registration tlum a--fir---- --
Address /I Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M:G-.L.c.1 152,'i 25C(6)j
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 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 fo_you under this permit.
The undersigned"homeowner"cerb-6en and assumes response ility foe mp iT ance with tiletate Building-Code-,-City-of-------- ----
Northampton Ordinances,State Local n' and Sta sachusetts General Laws Annotated.
Homeowner Signature
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Q Roofing
11vv�� Or Doors
Accessory Bldg. IL�.1 Demolition ❑ New Signs [CI] Decks [tom Siding(0] Other[Q]
Brief Description of Proposed G
Work: Buil(Ao_ 69f O S7b/l.l66 .S/7 a
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa, 1f.�Mew���o�as� ndrdc�i��oi� x+s`t n .tiousrncr �ompletetf�e�QCl�a�nu:
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? M o N G Fireplaces or Woodstoves �� Number of each
g. Energy Conservation Compliance. �` Masscheck Energy Compliance form attached?
h. Type of construction OAS
i. Is construction within 100 ft.of wetlands? Yes -j,No. Is construction within 100 yr, floodplain Yes_)�No
j. Depth of basement or cellar floor below finished grade g Q L
k. Will building conform to the Building and Zoning regulations? X Yes —No.
t
I. Septic Tank�� City Sewer Private well N Pt City water Supply t
SECTION 7a-OWNER.AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR'-CONTRACTOR APPLIES"FOR:BU(L (NG.:PERMIT~
I, 1 ' 1 i G .$, as Owner of the subject
property r I
hereby authorize LA. t l
to act on my behalf,in all maters relat1w t work authorized by this building permit application.
7 a2
Signature o wner Date
,N) c ( c 2
I, t c2.fC Q��d?N,rCC ,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.
JXPrint ame
Signature o wnedAge Date
` - ~-- - =
Section 4. ZONING All lnformatjbh 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 11—
Setbacks Front
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume�&Location)
A. Has | Perm�/Varanna/Rndi ever been �suadfor/on the sha?
' w-� DON7KNOVV ��^ x�� �
�� �,� v�u �~�
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry ofDeeds?
NO ��' "u'" ' "'"""" 0 '`^
IF YES: enter Book Page, and/or Duoument#
x�~� �~�
B. Does the site contain o brook, body of water orwetlands? NO ��. DON7K0OVV �~� YES �~y
IF YES, has permit been or need to be obtained from the Conservation Commission?
'
Needs tobmobtained »�� Obtained /~~^ Date\_� \�� '
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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb gd�g
or filling)over 1oc�or�hpa�ufo common p�n
�a wiUdi�urbover 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
� ��
- i + bf Northampton
BIIGIng Department
? �
12'Main Street
r,
Room 100 � �^
L{L 2 ,� c005NorftlEfht ton; MA 01060 e.v
phone 413-587-T240 Fax 413-587-1272
_41- -
---APPLICATION-TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This sect�on;to he completed by office
1.1 Property Address:
Vc
Zone OVerlayDhA ll,
`�Elie-fit:Distract � �'� _
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record: ll
c) 1 N(2 cti cToGt
,kgo C,Na e(Print Y Current Mailino Address*. �
Telephone
Signat
2.2 uthorized A e�n-t-:^
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
1. Building �x'2 SV,C , D O (a)Building Permit Fee
2. Electrical {b)-Estimated Total Cost of
D N Construction from 6
3. Plumbing /A A ,0�j G Building Permit Fee
4. Mechanical(IiVAC) 1j1 k 0NL
5. Fire Protection
6. Total=(1 +2+3+4+5) Check'Number —
ThisZection For Official Use Only
Building Permit Number'
r. ssued:
Signature:
i
Building<Commissioner/Inspector of Buildings Date
File#BP-2006-0092
APPLICANT/CONTACT PERSON ZAIKOWSKI MICHAEL C&GINA M
ADDRESS&HONE 30 BRIERWOOD DR FLORENCE O 586-4123 O
PROPERTY LOCATION 30 BRIERWOOD DR
MAP 29 PARCEL 090 001 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
T_ypeof Construction:_ERECT 8 X 12 SHED
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO)KMATION 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 Co n
Signature of Building Official 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.
,"No wo
30 BRIERWOOD DR BP-2006-0092
GIS#: _ COMMONWEALTH OF MASSACHUSETTS
Map:Block:29-090 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0092
Project# JS-2006-0130
Est.Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 17293.32 Owner: ZAIKOWSKI MICHAEL C&GINA M
Zoning.URA Applicant. ZAIKOWSKI MICHAEL C & GINA M
AT. 30 BRIERWOOD DR
Applicant Address: Phone: Insurance:
30 BRIERWOOD DR O 586-4123 (�
FLORENCEMA01062 ISSUED ON.812105 0.00:00
TO PERFORM THE FOLLOWING WORK:ERECT 8 X 12 SHED
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 8/2/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo