29-089 }
1
.v
� 7
t � � t.• N ���S
Y
a ,
t
4
i
Li
NO
Cp-pA�
WIN
r
N
7T"C�. �
�1L
Q-2)
�Cam. L•� �-� -r,_� `�j
r
Li
Sl
�go7�
Liz .05
(Lie,
� � ��� be
y M Y
�'CHwMP�,
Crzti of Nart1jamptan
�UASSACJt liB[tt8 -
cM �
DEPARTMENT OF BUILDDNG INSPECTIONS
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 !Js/her construction sup,::i."or. The sta-c 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
1, 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
s
PTO
B6 ��iSIIftChttSrttE '
m DEPARTMENT OP L(UILDD\IC INSPECTIONS
212 Alain Street ' Municipal Building
Northampton, Mass. 01060
WORICER'S CONUENSATION INSURANCE &M DAM
with a principal place of businessh-esidence- at:
(�vC7c�-T � - - 7 -= (}hone'=; -/ - 2�
=F-- - -
(stn_etici ty/statc�r�p
do hereby certify, under the and penalties of penury, that.
O I a111 an employer providing the following :vorr:ers compensation coverage for lily
employees Working on tiu5 job.
(Insuxanc� Company) (Poiic-;Number) ----✓ (Exrir;.tion Date)
I am <sole prophet general contractor or homeowner (circle ode) and have hired
the contractors listed below who have the follo:l:rag workers compensation poli(Iies:
(Name of Contractor) (Insuranct, COIIIT)any/Policy NtLmbcr) (EX 7:tnLOfl Date)
(Name of Contractor) (insurance Comnaiiy/Po!icv Number) (T :pir2tio Date)
(Name of Contractor) Insural}c� Coral;aiiyl'olicy Date)
(Name of Contractor) (InsLi-anc:. Comm,y/Policy Nub-r) Date)
(e[LU3t ad'!ttienal t!xet ift:ere-u: ::: cc,,::taming ell c :-ate.>:•)
i
( I aura a sole proprietor zlld have no oue �"vorkilla for 111e.
Z alll a 110111C oWI1C: r"'itCrlllln all tI1C wore: Iiivseli.
NOTE:ple:.se be ntvue that�.ilc k <r ou;r a.titre<: ploy r i:. to<. ,^n 2csand u^n m cr I-pair „i?, ^: :
no(atorc th_n thruo Unks in t�{ dt t x I�:,zvu2xr rcn:—'-A u oa t1u thereto c c oct G'crrrallV o .;:;%:::':c h
cntploy�a unicz llx worl cts ca,;._: !im A�(G L152.z 1(5)),zppl:c�aticn by n I o:tco rrr for a t:�C
legal ctatua of an o�ployor unu tl:a V,' ik lg Com;raz Iko Ad.
I understand that a copy of thin ctatcrcct atay Lo fotl.—d d to tbo I?cpervzr tit of Indiurriel A.eciLj,.&OtCioa for tin
oover-agc vtzification and that failure to r!atrc covrrnbo order section 25A of MGL 152 can Iad to tho impositia-t of mtnia l ptt allies
oomistutg of a ftnc of up to S 1,SW00 en 'x i priix cr1 of up to on-}w n.,d civil pcna16cs in dtc focrn of a Sic-,:VN'crk Order
firm of S 100.00 t da I Fun:.t¢r_.
For 6,;utM�Ga1 uic orttT� --------�
permit N(untx.r
Si6natu e v I Icca .-,fl
E
mu-4A R�*W7-7777777777777
;SECTII)N 8 CbNSTRUCTIQN SERVICES
8.1 Licensed Construction Supervisor: p Not Appjplili-c-�able ❑
Name of License Holder
License Number
Address Expiration Dat
4?g� 'Nl i=teq,tg>
Signat re Telephone
fia
R l ed: me imr'v em"en h. rac or, �, Not Applicable ❑
Company Name Registration Number
Address a Expira ion Dbte
O ( Telephone �6
SECTIQN�10 YVO`RKERS':CQMPENSATION 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....... e--' No...... ❑
The current exemption for"homeowners"was extended to include Owner-occupied Dwellinlzs 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
uv
SECTION ...D S R P71. O PROPOSEDIWORK% dFieck ll a licalile .y
sw. i .:
TA
,. ak AN `' ,ilia. ? w "V �KRAMW 'W#.;c'
New House ❑ Addition 0 Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs ] Decks Siding[ ] Other{
Brief Description of Proposed Work: R2-
Alteration of existing bedroom Yes _No Adding new bedroom Yes _ No
Attached Narrative 0 Renovating unfinished basement —Yes No
Plans Attached Roll 0- Sheet 0
6a, ff New ho se, Fi"d o a Ufflffl6ja isfingiKo-using cuff A lefie thelfol'h0Wi- :
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 76 OWNER�AUTHORIZATION -TO BE COMPLETED WHEN
OWNERS AGENT��ORCONTRAC70RAPPL'I:ES-FOR,'BUILD ING PERMIT
C Ef=tKima t a(�� _ __1 �` � as Owner of the subject property
hereby authorize 1_�'TT� J �> P`L'>Ti 1 �_ VM (`b`�►^ 4- C-c> LLC to act on
my�l�ehalf, in all matters rel tive towork authorized by this building permit application.
es
Signature of Owner Date
TM&ice VAA Kt 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.
AF--� V A-F7TA—
AM IM M& A
N m
Signat oll Owner/Ag nt V 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 -r—
Fronta e
Setbacks Front
Side L:i"I_R:2c--> L: R:Z '
Rear -7ci i _751 t3
O
Building Height 4.
� L e;
Bldg. Square Footage 2A,>-2- % Lt; '
`22
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 DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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:
j
City of Northampton Sat s oPerrn'
Building Department Curb ft#1
212 Main Street Se erg Se re a
Room 100 * a erg=t!tfe
Northampton, MA 01060
� ,phone, 4,:3 a�. .7 1240 Fax 413-587-1272 plo /Sete w'
APPLICATION TO•CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFO ATION
1.1 Property Address:
This section,to be3 completed by office
2Z� -UJc�c.�D _ Map tJnit
Z n Overlay Distnct
Elm St. District CB District
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�u<,�N�-°f' C_.r-IPG�'tZ►�l�_�� _�'�$�'�.C�24.Icx�� �j�2 �t_o__.
Narne(Print) �—� / Current Mailing Address:
Telephone _
Signature
2.2 Authorized Agent:
Name(Print)i Current Mailing Address:
i sig a re Telephone
SELION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permitapphcant
1. Building (a) Building Permit Fee
Ele:;rical (b :timated Total Cost of
Construction from 6
3. Plumbing 2_C9::> Building Permit Fee
2_C9::>
4 Mechanical (HVAC)
5. Fire Protection CJ
b. Total = (1 + 2 + 3 + 4 + 5) � Check Number
This Section For Official Use Only
Building Permit Number: � Date Issued:
Signature: ------- --- -
Building Commissioner/Inspector of Buildings Date
t
File#BP-2003-0977
APPLICANT/CONTACT PERSON JAMES VAN NATTA
ADDRESS/PHONE 403 SOUTH MOUNTAIN RD (413)498-2698
PROPERTY LOCATION 22 BRIERWOOD DR
MAP 29 PARCEL 089 001 ZONE URA/WSP
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: CONSTRUCT 140 SQ FT DECK&KITCHEN UPDATE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 040620
3 sets of Plans/Plot Plan
THE F LOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INY,ORMATION PRESENTED:
j 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 Str Commission
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.
22 BRIERWOOD DR BP-2003-0977
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map.Block: 29-089 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2003-0977
Project# JS-2003-1573
Est, Cost: $6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Groin JAMES VAN NATTA 040620
Lot Size(sq.ft.): 16291.44 Owner: KOSTEK EUGENE R&
f^_MIES VAN! N,A,7/.
AT.- 22 BRIERWOOD DR
Applicant Address: Phone: Insurance:
403 SOUTH MOUNTAIN RD (413)498-2698
NORTH FIELDMA01360 ISSUED ON.5116103 0:00:00
TO PERFORM THE FOLLOWING WORK.-CONSTRUCT 140.SQ FT DECK & KITCHEN
UPDATE
POST THIS CARD SO IT IS VISIBLE FROM THE STREET_
Inspector of Plumbing Inspector of Wiring D.F.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough:sl�� House# Foundation:/-7?/�
S O�Rough: G'
t Driveway Final:
Final: Final: ����'��3 ��
Rough Frame:g k
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: r.suiation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLA'T'ION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate Of Occupancy Signaturr j
FeeType: Receipt No: Date Paid: _ _ Check No: Amount:
Building 5/16/03 0:00:00 822 $50.00
?'Ma r,S-ePt;P"one(413)587-1240.Fax: (413)587-1272