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`j” a_ " DEPARTMENT OF BUILDING INSPECTIONS '�
INSPECTOR 212 Main Street • Municipal Building ' o
Northampton, MA 01060 ,~ S`��
e
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(: Hsor. 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
,.
,
Itln.1 -fA t
,,� � � • yE (rif a:f {arfl nip A * .
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DEPARTMENT OP fUILDD G INSPECTIONS —..
212 Main Street ' Municipal Building t
Northampton, Mass. 01060 r `
WORKER'S COMTENSATIO.N MSTTLZ CE AFFIDAVIT
•
__ J2h n ��t VIS .....____
(li ccnsx ttcc )
with a principal place of business residence at: —
`;-; biWOCV S 1 r iit'Y - O? 1 (phone") S7 y •-6S
(w=1/o7r /sta.trfap)
do hereby certify, under thc.pains and penalties of perjury, :hal .
( ) I am an employer providing the following!1.vorkcr's compensation coverage for my
employees wor'ng on this job:
(Iu_m_o CompanCompany) (Policy Number) — (T1:pircion D2) .
..
( ) I am a sole proprietor, general contractor or homeowner (cis-0:e one) and have hired
the contractors listed below wbo have the follow.ring worker's compen_ anon policies:
•
(Name of Conf-r cior) (Insu mnct CompanyfPouc; Nuratc :) (t' :ptr - a n Date)
•
(Name of Cono-anor) (Irs,Iranec Company Policy Nurilcsr) (E nir=tion Date) -
(Name of Conlzanor) (Lnsurarzcz Compare } •fPoUc y Nambi) (Expiration Dale)
(Name of Contractor)
(Insurancc Compz4y/Policy Number) (Expiration Datr) -
(aCaCjJ adaitiocit.1 rSea.if nee_.0 --v to a dv iaforcu.•ioa peter.' to .11 w= -rocs)
•( am a sole proprietor and have no one wog for me.
( ) I an home owner performing all the work myself.
NOTE: plesc be .cerise ti.-.1 • ,. o bC .-ocr] ...'bp G=007 pCS-061 t11 do 2 ,,, r — �.:r_,ao c rt o wont az a dwcili=7, of
not meet: tben t_' =as is web the bomoo- we raider a,- oa the grouad, z,,puttea.a tbeco r-: ax c..-= -Ry ec...d. to be
czplor - ur the ..awl crne - - :ca Aa (GUI 52.= l (5)). app(ici600 by • bomca•aa fc c li or permit cr=y es-ic moc the
l•- l n-• ., of .a o loyx uodor the W oci.da Coos ,om..tioa Ad
I uodcsxaad th.2 a copy of tb.. mtcmom may b. foa>.erd.4 to tbo Dop.rcmm¢ of 1. +4c1 Acsidoots' Moo of Ir..w•..• for tb.
oovCasc ve.'if etioo .ad thei ED= to =curs tovcrasc „ ere- section 25 A of MOL 152 c o led to the it rxa+fion of eimiasl PcsalLicz
oocoszig of a fioc of up to S 1 }OO.00 .adror - a, of up to o« ye-r cod cv11 peo•hic, is be roan or. Stop wort Or "I'd
fi>x of s100.00 a ny aCtir r>x
// For des, v ',� =31 u.c only
` permit Number •
1' 4 / 6 /to I tw(an: -- Lot K . i
k'
Stta.� Af l_r v
In - It7r.,,.
( k., 1" 4. - 1
r ,
SECTION :8 - CONSTRUCTION SERVICES Y
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder : 'q,-.)h Y1 IA In K N )
License Number
I�1mdc L S Lao (-I ni\A ) 1A
Addre Expiration Date
q _
Signature Telephone
.g .2e`gisferedEfor re tiiproverrre'nl_Co actdr .A , . t 1 Not Applicable ❑
—3-47 LA 75
Company Name Registration Number
),'f c c41 S 1 Lepry WIA 6 �
Address Expiration Date
Telephone 57'V - SS
SECTION 10- WORKERS' COMPENSATION INSURANCEAFFIDAVLT (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 ❑
1 .t o f a OWern - o
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
r
SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable)
New House 0 Addition Q ; Replacement Windows Alteration(s) n Roofing n
,�,,/ Or Doors D
Accessory Bldg. LJ Demolition Ei New Signs [0] Decks [D Siding [D] Other [l ]
Brief Description of Proposed /•1 x14) # wcxr' S�in-S-All 7t '; C'Y6 'Su nk'Z7 *ifs cM I .g'C icuil? /414 ' � ►xg2`cx -20 a " ti;
Work: SA.(ic 'TA rn sP.(kvirSh,v+
Alteration of existing bedroom Yes E.- Adding new bedroom Yes L-" No
Attached Narrative Renovating unfinished basement Yes p� No
Plans Attached Roll - Sheet
6 [f Never - horse iii a itia &Vi tic cf'ha sir` ct r6a6 et ftia t q:
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 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 7a - OWNER AUTHORIZATION - TO BECOMPLETED WHEN
OWNERS AGE OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r
I, F a AS .1) 0 , as Owner of the subject
property
hereby authorize Ii N ( A V(S ,b
to act on my behal i all matters elative to work authorized by this building permit application.
G .ufi L J ter. `- //' 6 /ilk
Signature of Owne Date
I, r) M IIA i fn N c NT , 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 -, : •enalties of perjury.
to 14 N g
Print Name
fi► L 4/0
Signature of Owner • gent Date
Section 4. ZONING All Informatibfi 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 aW —
Frontage — __
Setbacks Front I
Side L:`. R:. L.: R:__
Rear '
Building Height ;
Bldg. Square Footage
.
Open Space Footage %
(Lot area minus bldg & paved
t
parking)
# of Parking Spaces
Fill: '
:l
(volume& Location) '_
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 DON'T KNOW 0 YES 0
IF YES: enter Book ' Page; ' and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T 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 a
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 Cr
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 Q , NO a
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
- 1
City of Nofampton o Pe �
Building Department rt � ' s utD :
212 Main Street dew �e t � at
Room 100
< 74
pa !
((��
Northampton; MA 01060 s o .5�
� � 2 6
one 413- 587 -1240 Fax 413- 587 -1272 "
1 3 1E ]t�$+it� anSz � � ' � . ,., � f a� .� �
`Otherr;SpectfY a ;� + ,,;aka;'s ; - '� ,, .' ,� -`" .. s �:.'.,, -'.
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1. - SITE INFORMATION
1.1 Property Address:
This section-4);_ be completed by office
G Lt 14 4t))6' ST 0Map Lot Unit
M G r) rl !9111 lGti1 /1/1 Zone Overlay D fnct '
El St Di CB District
SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGE
2.1 Owner of Record:
Pa I D vG •
q Si h ,� f vrlA
Name (Prin , Current Mailing Address:
:Q S7'/ 7 S
it Lit.L. Telephone
Signature
2.2 Authorized Agen
v 1 t I u ti S S /ii GG4 s% Zee i 4 .
J
Name (Print) I Current Mailing Address:
�—
. s� Y- 5 S 33
O
10 1 Telephone
Signature
SECTION 3 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building k'} z c ll. C (a) Building Permit Fee
2. Electrical n (b) Estimated Total Cost o
ii �7 Construction from (6)
3. Plumbing Building Permit Fee
4. Mechanical (HVAC) / y�
5. Fire Protection n ! /
Check Number 61/
6. Total = (1 + 2 + 3 + 4 + 5) dt�f Sv.
T his - Section For Official Use Only
Date
Building Permit Number. Issued:
Signature: r
i
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0945
APPLICANT /CONTACT PERSON JOHN PUNSKA
ADDRESS/PHONE 5 Dimock St LEEDS (413) 584 -5533
PROPERTY LOCATION 94 HAWLEY ST
MAP 32C PARCEL 234 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid b
Tvpeof Construction: CONSTRUCT 12 X 10 SHELTER
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 039852
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFQRMATION 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 Commission _ Permit DPW Storm Water Management
Demolition Delay
C - 112V(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.
94 HAWLEY ST BP- 2010 -0945
GIS #: COMMONWEALTH OF MASSACHUSETTS
Map :Block: 32C - 234 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
Permit # BP- 2010 -0945
Project # JS- 2010- 001404
Est. Cost: $2850.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JOHN PUNSKA 039852
Lot Size(sq. ft.): 32582.88 Owner: DUVAL PAUL H
Zoning: URC(100)/ Applicant: JOHN PUNSKA
AT: 94 HAWLEY ST
Applicant Address: Phone: Insurance:
5 Dimock St (413) 584 - 5533
LEEDSMA01053 ISSUED ON :5/3/2010 0 :00 :00
TO PERFORM THE FOLLOWING WORK: CONSTRUCT 12 X 10 SHELTER
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 5/3/2010 0:00:00 $55.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo