30B-001 O ,.SYTAM P70 ("`�' ", i
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'"" DEPP �.TMENT OF BUILDING INSPECTIONS ' =_ � ;
INSPECTOR 212 Main Street • Municipal Building '�
Northampton, MA 01060 .
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as its /her construction sup:- - :;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 bacldiill).
sonotube holes (before pour). a rough building inspection (before work is
concealed), insulation inspection (if required) and a_final_buildina 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 ti The Commonwealth ofMassachusetts
Department of Industrial Accidents
„ Office of Investigations
•
"° ("' `Q 600 Washington Street
- -`` Boston, MA 02111
' -4." www.mass.gov /dia
Workers' Compensation Insurance Affidavit: Builders /Conn - actors /Electricians/PIumbers
Applicant Information Please Print Legibly
Name ( Business /Organization/Individual): S Th'\ 1 yr,rt� / I z u (.4..
Address: 1 2- 6 1. o. _*..,- 12
01373
City /State /Zip: Se,,c — Ocer^ r, G l e Ark Phone #: Y(3 —(?c
Are you an employer? Check the appropriate box:
Type of project (required):
1. ® I am a employer with 4. 0 I am a general contractor and I
have hired the sub - contractors
employees (full and/or part- time). * 6. ❑New construction
2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. El Remodeling
ship and have *_+o employ ees These sub - contractors have g. 0 Demolition
capacity. employees and have workers'
working for me in any p t'• 9. ❑ Buildine addition
[No workers' comp. insurance camp. insurance.:
required.] 5- fl We are a corporation and its 10.0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11E Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.✓Roofrepairs
insurance required.] t c. 152, § 1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*xny applicant that decks oox 4I must also rill out the section below showmg their workers' compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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 must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees: Below is the policy and job site
information.
Insurance Company Name: I- 1 t a4) l `1t,' .1( ,1.., s,,,.,,,.,,,, Co —
Policy # or Self-ins. Lic. #: tti C 1 - 3/ 5 - 3ti 10I 7 - 02._ l Expiration Date: 5 c. 7/ 2
Job Site Address: / 3.;,2 w,o•A,e, S / City/State/Zip: /14 ,.- 1-40,«., ...... 11 -7,°- ato`
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one -year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investinations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjuzy that the information provided above is true and correct.
— gionatni G -e -� l_ '.� ( Date: / / _
Phone #: `((3 - 04".3 -702 )
, Official use only. Do not write in this area, to be completed by city or town official
if
�
City or Town: Permit/License
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City /Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone 7:
SECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : . J LJVLfi..) A_ mt Z U 1 . 4
License Number
1 ,Pi' ; ,,, Does Fi 1174. a /_3-7.3 n y ?o L
Address
_ Expiration Date
if /3 4 (vP' 7d�7 / /A /5—A/
Signature Telephone
9 -,Re irsferedtkiitie_Triibn: eiire t*ContracforEZ ., , . x5 Not Applicable ❑
Company Name // Registration Number
S �v aril ri Zw l tt �a � ;.e e late vs
Address Expiration Date
.27 I Telephone YIf -?oi7 / / � 331
SECTION 10 WORKERS' COMPENSATION- INSIJRANCEAFFIDAVIT (M:G L. c. -f52, §,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 l/ No ❑
11 mom &Owffe gemPx an
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 - vear 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) n Roof g
Or Doors D 1
Accessory Bldg. [l Demolition ❑ New Signs [0] Decks [[] Siding [O] Other [0]
Brief Description of Proposed ( 1
Work: )S0..,+...o..<c o'o rd le.0 , � �� sum O :.�a r )e f 4 �. 4 .�c.�
Alteration of existing bed com Yes No Adding new Yes No
Attached Narrative Renovating unfinished basement Yes - No
Plans Attached Roll - Sheet
sa. Nevu�r- house -arid or- "a+<iciFfrari__fa.�xrst> Ens- �ousi,��a�uCe1€�t�a�Fa��c:
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 withirr1 yr. floodpleh, 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 - OWNERAUTHORIZATION -TOE COMPLETED, WHEN
OWNERS :AGENTOR " CONT}?ACTORAP.PLIES FOR. BUILDING: PERMIT
I, A , as Owner of the subject
IL
property ,
hereby authorize S J g,) .5, N T '? f z u l
to _ ton my behalf, in all matte relative to work authorized by this building permit application.
�t LC 4_ _Ai1.41,
Sig cure of Owner " Date
1, _S ✓r�.��? r Z u rr� , 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
/J •m� %t _ „.7.1.0///
Signature of Owner /Agent (•�
.t
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incompife Information
Existing Proposed Required b} Zonfria
This column t: be filled in by
Building Dep. .. ent 1
i
•
Lot Size u
SFr` - .1
Frontage
Setbacks Front .
Side L: _ R L: -. R
Rear •
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bld & paved
Parking) } f
# of Parking Spaces
Fill:
(volume & Location) y
A. Has a Special Permit/Variance /Finding ever been issued for /on the site?
YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Pager and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained ® , Date Issued::
C. Do any signs exist on the property? YES ® NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES ® NO Q
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading, excavation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO 0
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
I; t ? epartrnert erne anNi
its of Northampton st- trr -
•
uilding Department cCur� C LDpr . it : – e 4 €
RECEIVED
212 Main Street Sewer�Sept� . a . : - i - . k.
i Room 100 afer/Ffi(etfAzsaabtf�r
• iMN No hampto MA 01060 0 Se o StEac€urat Ptans K
phone 13- 87 -1240 Fax 413 - 587 1272 Pta sit=e PI"an
NORTHAMPTOIL BUILDING W O1Oi S5therSpec _ . _ . _ _ „ _ . .-
__ ...
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOV ATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
--S�
- SECTION - 1. -SUE INFORMATION - --
1.1 Property Address: .
Tfiis �oc be compfefed tiyOffce
M pz l=ot Uiu
Zone Overfay Drstnrct
�L.,. c
SECTION2- PROPERTY OWNERSHIP /AUTHORIZED AGE k'T
2.1 Owner of Record: Fta�� 01042 2-"i jU
J c, Se EA Go.'.>S r 3z. (,•r,o✓ ,�,+,1 S 44744.....4.,„ h?/�. cmJao
Name (Print) Current Mailing Address:
� � — Shy - y�
AI _ ,� � _ v .....,_x_. Telephone
Sign_I re
1
2.2 Authorized Anent:
ST'�v�ti A - 1►‘,Z�l i��sx,.i So f /
Name (Print) Current Mailing Address:
a �� 4(5 e,(0,- -70? -
Signature Telephone
—
SECTION 3- ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building (4 Building,Perrnit Fee
2. Electrical (b)tEstimated > Tntaf Cost _of � -� !
- Construction. from (6) '10
3. Plumbing Building. Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total = (1 + 2 + 3 + 4 + 5) Check Number oz j m a r,
This Section For OffciallJse Only
- - "D'aCe
Building- Permit Number. ' Issued:
Signature:
I Building Commissioner /Inspector of Buildings Date
f '
132 WARNER ST BP- 2012 -0001
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 30B - 001 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- 2012 -0001
Project # JS- 2012- 000004
Est. Cost: $2407.00
Fee: $35.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: STEVEN MIZULA 024706
Lot Size(sq. ft.): 27704.16 Owner: GONSKI JOSEPH ANTHONY & CATHERINE MARIE GONSKI
Zoning: URB(100)/ Applicant: STEVEN MIZULA
AT: 132 WARNER ST
Applicant Address: Phone: Insurance:
127 PLAIN RD (413) 665 -7027 WC
SOUTH DEERFIELDMA01373ISSUED ON:7/5/2011 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 7/5/2011 0:00:00 $35.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Louis Hasbrouck — Building Commissioner