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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 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 understand the above. om o er resident's signature requesting exemption) I will call to chedule all required building inspections necessary for the building permit issued to me. Date 7/ /GY Address of work location The Commonwealth opfassachusetts Department of Industrial Accidents A ., --,•:_-=, 1 Office of Investigations 600 Washington Street f. =7 •..7 Boston, MA 02111 -4 -,.--- --,,,• www.mass crov/dia , • - Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name Pusiness/Organization/IndiviritinD: Address: ,. City/State/Zip: - Phone .#: Are you an employer? Check the appropriate box: . Type of project (required): / 1. 0 I am a employer with 4. 0 I am a general contractor and I 6. 0 New coistruction employees (full and/or part-time).* have hired the sub-contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet.. 7. 0 Remodeling • ship and have no e>loyees These sub-contra.ctors have 8. 0 Demolidon employees and have work. - working for me in any capacity 9. - EiBuildink additiOn LNG workers ' comp-. insiirance _ comp.insurance.T__ _ 10.0 Electrical. repairs or additions 5. 0 We are a corporation and its 37p I am a homeowner doing all work officers have4xercised their . 11.0 Plumbing repairs or additions 1. myself [No workers' comp. right Of exemption per MGL 12.0 Roof repairs . - insurance required.] t • c. 152, §1(4), and we have no employees. [No workers' 13.EI Other co MP- inSillanCe regiEed-1 • • *Any applicant that checks box #1 must also fill out the section belowshowing theirworicers' COMpensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. . Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees, they mustprovide their workers' comp. policy number. • lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site irzformation. . Insurance Company Name: • , - - Policy # or Self-ins. Lic. #: Expiration Date: Job Site Address: City/Stafx/Zip:' Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required tinder Section 25A ofMGL c. 152 can lead to the iMpOSitiOn of criminal Ptenalties of a fine up to 51,500.00 an.d/or one-year imprisonment, as well as civil penalties in the forni of a STOP WORK-ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of afeitiiiitions oldie - DIA: for insurance c-0v61: verification . . - T :. _ Ito ____eb_y_ +357 der the pains and p , , • - of:perjury that the informationprovided:above • , , , , jrPrt Iirt e: - Alt Ai r e" _ , . . . d - • l ate - . --gbi .7" /c) • , .. Phone #: / ( //...1 - .3 ' re79 - . . - Official use only. Do not write in this area, to be completed by city or town'officiaL I City or Town: Permit/License # ----.. Issuing Authority (circle one): • . '. ' ... . 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical,Ins pector 5. Plumbing Inspector 6. Other Contact Person: ' Phone #: SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : License Number Address Expiration Date Signature Telephone OT:;Rekiiitiiia, Not Applicable ❑ Company Name Registration Number 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 ❑ 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.: f. cal Zoning Laws and tate of Massachusetts General Laws Annotated. Homeowner Signature � ,i/ /, _ /fe SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House 0 Addition ❑ Replacement Windows Alteration(s) 0 Roofing Ej ,�,/' ,--�/ Or Doors D Ac ssory BId . [Id Demolition L� New Si! ns •• Dec �� Siding n Oth - r [0] Brief Description oaf PruPosed / / � j Work: /14 /(401 1�It She/ a 01 c,0 i .7i4.. pat .v 4 C, Alteration of existing bedroom Yes No Adding new bedroom Yes A-- Attached Narrative Renovating unfinished basement Yes c�No Plans Attached Roll - Sheet or iilvIt d rov r`3stps lilra Q ktilte` acii iii : a. Use of building : One Family Two Family Other S�4'i_/ CG i" b. Number of rooms in each family unit: Number of Bathrooms ,-R c. Is there a garage attached? (lr) d. Proposed Square footage of new construction. Dimensions /Co ')(.70 ')(.70 ' s4 /84 'L)C`C/ . e. Number of stories? 111 S /ory 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 4- No. Is construction within 100 yr. floodplain Yes 4---"Isl o j. Depth of basement or cellar floor below finished grade l f r k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION Ta - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, J� Z - S /7/ $ , as Owner of the subject property hereby authorize to a behalf, i all ma ers rel ive to work authorized by this building permit application. ier el f l4M - Sign Sign - ME ner 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 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 m Lot Size i ? Frontage - Setbacks Front I i i 1 y Side L:I € R:= ._ .1 L:1 L:= R:I a g 1 Rear l l I Building Height i Bldg. Square Footage I , I 1% [J 1 1 Open Space Footage % i _ 1 (Lot area minus bldg & paved .: _ I parking) — # of Parking Spaces a Fill: 1 £ I (volume & Location) i t A. Has a Special Permit /Variance /Finding ever been issued for /on the site? NO 0 DONT KNOW YES 0 IF YES, date issued:! IF YES: Was the permit recorded at the Registry of Deeds? NO 0 DONT KNOW YES 0 IF YES: enter Book , Page ? and /or Document # B. Does the site contain a brook, body of water or wetlands? NO e r DONT KNOW 0 YES 0 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 0 NO IF YES, describe size, type and location: 1 D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO fer IF YES, describe size, type and location: s I E. Will the construction activity disturb (clearing, grading, ex ation, or filling) over 1 acre or is it part of a common plan that will disturb over 1 acre? YES 0 NO IF YES, then a Northampton Storm Water Management Permit from the DPW is required. City of Northampton B Ilding Department \, 12 Main Street �: r Room 100 rthampton, MA 01060 phone 413- 587 -1240 Fax 413- 587 -1272 I Ito APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION I 1.1 Property Address: Unit This section to be completed by office 7// % Map lot " 1 ce !'iG 0/00.7 done Overlay is trlct Ekri St 'District Ca District SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: .C':ZL --.F :4 4 ` � `js9/>>�- Nam= - rint) Current Mailing Address: ia- Telephone Si. a is 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 compl ted by permit applicant 1. Building 9100 (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 o/1601.5.-- �J This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2011 -0067 APPLICANT /CONTACT PERSON STANKOWSKI JOZEF & JENNIFER ADDRESS/PHONE 211 ACREBROOK DR FLORENCE (413) 586 -8049 O PROPERTY LOCATION 211 ACREBROOK DR MAP 29 PARCEL 363 001 ZONE URA(100) //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 Cie 0 Typeof Construction: REMOVE 2 SHEDS,PORCH/DECK & CONSTRUCT 16 X 20 SHED & 14 X 30 DECK 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 INFORMATION PRESENTED: L/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 Commission Permit DPW Storm Water Management Demolition Delay "/ 6 to 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. 4 ` A . t t BP- 2011 -0067 GIS #: COMMONWEALTH OF MASSACHUSETTS ►` "._ Iock:=2 - 363 -t:rf 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 Pennit # BP- 2011 -0067 Project # JS- 2011- 000120 Est. Cost: $5400.00 Fee: $148.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 16335.00 Owner: STANKOWSKI JOZEF & JENNIFER Zoning: URA(100) / /WSP Applicant: STANKOWSKI JOZEF & JENNIFER AT: 211 ACREBROOK DR Applicant Address: Phone: Insurance: 211 ACREBROOK DR (413) 586 -8049 0 FLORENCEMA01062 ISSUED ON:8/17/2010 0:00:00 TO PERFORM THE FOLLOWING WORK: REMOVE 2 SHEDS,PORCH /DECK & CONSTRUCT 16 X 20 SHED & 14 X 30 DECK 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 8/17/2010 0:00:00 $148.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner