43-098 (7) �St1AA1Pl. r
O 4
�� tig Ctyz#� >af ��z#f��ut�t>xtr z
�835AC�llStt19
i P
t
DEPARTMENT OF BUILDING INSPECTIONS /=
iNSPECTOP 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 !:is/her construction supc.; .-or. 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
n l r
-
R `ti ulf� of �,Torfljulli} foil
w DEPARTMENT OP BUrLDr),,'C INSPECTION'S '
212 Main Street Muoicipal Building
Northampton, ATnss- 01060
tVOIUCCIZ'S COi\'MENSA_MNJ -MSU ANCE A1=AVIT
(li ay.s.•xJperml ttcx)
wll.h a principal place of business/residence at:
,—
S"�' Wic,�.-, 1•���:�,-r,�c� !`'I�l� �. �o��z.._ (phone') ��'�.. r ,�•��
(stz-�.t/ci i-r/sZaicla p)
do hereby cerzify, under the pains and penaRies of pcgufy, hRl
( ) I am an employer providing die following vuorkcr's comocnsadon coverage for Iny
emplovecs wor!dng on utis job:
(Lasuxan= Comp=y) CPclic: ?:iLmbcr) --- (`:-pir<tion D2j--)
( ) I am a sole proprietor, general contractor or homeowner (ci cie one) and have hirea
the contractors fisted below who have the following worker's c000easann pakies:
(i`+smc of CO:=C-,or) (tn umncz- Comoan)•i?rUc-, N'uxnhc:) (-Exoirauon Date)
(Name of Contractor) (lnsurancz C.omuaivi?ok-i \uracrr) (Expiraiion Date)
(Name of Conrracto:) aasuraoc Comr,=y[Pol q• Nadu) (Expiation Dalc)
(N2me of Contractor) (Lasumn= Compwy/Poliey Number) (Expirtioa Dail).
(&M Ch ads.:oczl rbc—_irno:>.-•W alciu�iaform��oc pcu_iaias w.11 cc¢r-.r_v:7) i
C
I am a sole propnetw and have no one wor',zg for me.
( ) I am.a home owner perforruiug aJJ the work myself:
NOTE:plcsc be-wise dL,i Jo hc`m'c�o ,,, to c�lcy pcL=Lo do r c��L c rcna wart oa.d� 1L:L of
pot more tb� f oc�i-s in u.�tll lbC v,ny�w�7T13 Or Oa LbC QOUyyy Z�pul1LO.`[?�C'GO LT we�_r.11y oc�d-cil w t-
eixployv-�e�nr'�e the�.a-S;c'z Lea Act(GL1S2.s t CS)�aP9ti�tion try a hommava fcr-��x«po-mn rimy c��dr�«etc
1cV1 ntuc of ea=Player under dap Wockc -a C.o�on Acx_
I uadcri d tba>oopy or thin zue may tx forte erdnd b tbo Dep.nnxea or Ioduuicl Aeodeso Off o0 or Irau.00e for the
cove &- vcriGcaiioo and Oi:t L•Jart to xomm bo%crasc tmdcr 14c600 23A of l.(OL)57 can!cd to the i�OQ of ciminal pccaL6cz
eoaiLs ig of.fiat of tp to S 1 X00.00 a O/or mmprisoaox or up 1n ooc ye_r end coil poaa.tio in 6c roan of e Slop Wort-Or'drs end a
C=of 5100.00 a day xplwl me
For
rPCraiji Numb=
L Lot
SigttUT;�of I_iC=SCrJPCrmittcc ice
f ,
k
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: ) Not Applicable ❑
Name of License Holder VVJ, `? 0-7 11 —7
License Number
7- Ll -zY -u"7
Address Expiration Date
Signature " Telephone
9Reglsteed lone}lmpr`ovemenCnnfeactorx t Not Applicable ❑
L .�,,.(,� ►'�-�c�r.�C .c( �S f`acv ��3
Company Name
y^� Registration
°yNumber
7 ` �1✓�G�1✓l �(C3�.�,H�„Z I'7 v1'�l�c.'Z Li-1 C ° �J
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE.AFFIDAYIT'(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...... ❑
r # ��are
tic
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 ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [[] Siding [0] Other[❑]
Brief Description of Proposed
Work:
,I
Alteration of existing bedroom Yes _No Adding new bedroom Yes ' No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sayff Newnhous anc erAdclltiofiA&exrstrn io srng comp et the of!'ovu g:
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
1. 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 7a7=OWNERAIJTH- RIZATION-TO BE G-OMPLEE-T-EDP-WHEN--
OWN'ER�SAGENT:OR"CONTFMGTOR_APPLIES FOR BUILDING.PERMI.T
tit (e(e P-\ I q1, t2 as Owner of the subject
property
hereby authorize
to act o my behalf,in all matters relative to work authorized by this building permit application.
_.._,_. .Z L' ')
Sign ure weer Gzte
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.
AL,CJ
Print Name
Signature of Owner/Agent 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
Rear
Building Height
Bldg. Square Footage %
Open Space Footage -------- %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has u Special Perm it/Vorianoe/Findi ng ever been issuedfnr/on the site?
�� ��
NO \_�� VV t��/ D0N7KNO YES v_�
IF YES, date issued:;,
IF YES: Was the permit recorded at the Registry ofDeeds?
NO �� DON'T VV KNO YES\=�
IF YES: ' enter Book Page, and/or Documont#
�� ��
B. Does the site contain ubrook, body of water orwetlands? NO \_� DONTKNOVV x_� YES �_�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs tobeobtuinad ��` Obtainad v�� Date
�_/ \~� ' �
C. Do any signs exist onthe property? ��y? YES \�� NO �_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 00 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing, gradingexcavation,nr filling)over 1 acre nrisit part nfo common plan
that will disturb over 1acre? YES [��) NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
Deparment�use only
City of Northampton statusiP �
Building Department F
212 Main Street 5euuer e QatkeEx � x�
Room 100 i�Y.
ila6t _ � � �
Northampton, MA 01060
- - -R` .413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1,-SITE.INFORMATION
1.1 Property Address
T his sectro to he co m pleted by�office
UtuL
Zone =WOuerlayDristcic� -
`.'{'�tY leis LLJ CrI �:{ � ,y". ._�f��^JtCJ4l µ q ., •.
,SECTION-.2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
�[ 2.1 Owner of Record: } )
Name(Pri t) Current Mailing Add ss:
Sign re
- vt-
r Telephone
2.2 Authorized Agent: 7
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 (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=(1 +2+3 +4+5) Check Number
This Section:For Official Use Ord
Building Permit Number.'' Date
issued:
Signature:
Building Commissioner/Inspector of Buildings Date
' rt r BP-2007-0763
G1S#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: roofing BUILDING PERMIT
Permit# BP-2007-0763
Project# JS-2007-000544
Est. Cost: $5000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: C PHILIP ANDRIKIDIS 150673
Lot Size(sq. ft.): 72309.60 Owner: CELENTANO JOHN
Zoning: SR Applicant: C PHILIP ANDRIKIDIS
AT. 19 WHITTIER ST
Applicant Address: Phone: Insurance:
52 MAIN ST (413) 585-9171
FLORENCEMA01062 ISSUED ON:21612007 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: Date Paid: Amount:
Building 2/6/2007 0:00:00 $25.001242
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo