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"= DEPARTMENT OF BUILDING INSPECTIONS =,_ _ /_
INSPECTOR 212 Main Street • Municipal Building ', =
Northampton,MA 01060 -
igi
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supc: .' sor. 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 i egulations. 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
r
r
•
i
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DEPARTMENT OP 13UILDT G INSPECTIONS • _ _
212 Main Street - Municipal Building
Northampton, Mass. 01060
woRxcER.s COMPENSATION '�ISU N
RACE AFFITM.\'-IT
1, _kJ CA,P".es ("- tot/ ...._._.__.
(lic s permittec)
with a principal place of businesslresidence at:
l l 14.e,,,,,y S t F 1.',,r 4- > (phoney° "fir-•-a/C( — ii
(strt~.t/ci t}�stat / p)
do hereby certify, under the pains and penalties of perjury, hai
( ) I am an employer providing the following worker's compensation coverage for my •
•
employees woridng on this job:
(Is - Company) (Policy Nes r) :piatior Dau)
.
( ) I am a sole proprietor, general contractor or homeoW-ner (circle one) and have hired
the cona-actors Listed below who have the following worker's compensation policies:
(Narnc of Contractor) (In w-anoc Cordon+-Iyi oUCi NuIIl_Cr) (:pir tion Datc)
(Namc of Contractor) (Insurance CompanyPojc Nunc_r) (L): irtion Date)
•
(Name of Contranor) ansuranec Compan y/polio}' Numbu) (�xpirotion Dale)
•
(Tame of Contractor) (LnsZtranc: Comratr;/Policy Number) (Expiration Date).
(an..th`1`.061 rbcu.tf noot=z'y to indt3&inforlLi7oc pc-l..=ns to a OOa.'•-..Gd7)
•
-j ,O. '1 I-am a sole-proprietor and -have no one world:-rag for me.
( ) I am-a home owner performing all the work myself.
NOTE:PI --4,-- cw'-uc lt.••..r.le bemco vocro wbo employ pcsooa to do r- :,...-•,m c—.:=Joo c-tgau..-orz co z d..ctl:^7.of
not tow=the L ro tmitr is with the bomoowo=raid=or oo the p-ou do xt p rten_•s tbcon Li o- C-rrlly coe=d-ni to be
enploy=s ua the wx; rte..., * A (G121.52=1(5)1 nppticsrioo by a bom»ays fc a ti --or pewit nz.ny rvid=oc the
Irg.l nano or an ospioyr coder dzo Woritcez Compemayivn AU
I,:ode-cus d dui a copy of this moot eo.ey be forword.d w the
Dcgertmze of Indus—rid neodeata'office o(Irzo+r.oce for th.
Cevc"-hc veifiatioo:sod th1 allmm to sc urt:bovcracse„net,-•lion 25A or MOL 152 cap Ica!to the i=positioa of e-izniail pc,,ttia
coasis:as ora ftac of tip to S1.500.00.reor iszprioocroo=of up 1.0 ooc year Lod dvii pmzttio ie the form of a Stop Wort Or and a
fxoo of 5100.09 z dzy tzaidSt me
For doy ,u.c only
Pc-rmtt I`tilSlt)CS
0/� A4an-—_ Lot "
Sites• - •�'a�ser/Pcrrniu= - e -- -�
SECTION 8-CONSTRUCTION SERVICES ,,1"
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
{, -•- . .: .: . �• 4 ,4 � ; Not Applicable ❑
'SeQ'"`isaFere"� rne�inpEOVemer��`
1S Z9 2 (
Company Name Registration Number
Address Expiration Date
2t// Hen ��, Telephone `ii)— 2i -11CI / (9 ZQ/ c(�„9 l/ l I
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 tk No 0
The current exemption for"homeowners”was extended to include Owner-occupied Dwellings of one(I) 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
P-
I
SECTION 5-DESCRIPTION OF.PROPOSED WORK(check-all applicable)
New House ❑ Addition n; Replacement Windows Alteration(s) ❑ Roofing IT
Or Doors El
Accessory Bldg. ❑ Demolition ❑ New Signs [D] Decks [p Siding[D] Other[D]
Brief Description of Proposed (?
Work: I(.L_ ('v'0 lei ` l
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
say t AT,fia eon arfi-a fc eac�st%nc r 6I slifilW mp irati ,_ a Hilt fa:
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?
1. 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 BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLES FOR BUILDING,PERMIT-
I, 00/&-e S Q Q'f,JC2`({JS<I ,as Owner of the subject
property ---. "^�"
hereby authorize JC,1, (5 A- C ` r i S CI-'('',..'
toact be , n711 matters r ti a to work authorized by this building permit application.
Signature of O -�� a Date[,---1 ,,,,,, ' ,as Owner/Authorized
Agent hereby eclare 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 enalties of perjury.
- k !n e) °t VIII
Print Name
4 ..„---
,.._......._ if „3
Signature of Owner w. Date
Section 4. ZONING All Informatibfl 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
, e 1
Lot Size
# i
Frontage
i H i ;
Setbacks Front i f
Side L:' R:' ` L: R: , I.
Rear
Buildin
g Height
i 4._ f
Bldg.Square Footage i f
Open Space Footage %
(Lot area minus bldg&paved l ' #
parking)
i 1 1
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 6 DON'T KNOW 0 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 0 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 Q Obtained Date Issued:
C. Do any signs exist on the property? YES 0 NO I
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 4.7,
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 r NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
1 tf
NbUE VET � t e
—
City of Northampton x 7 'M1 , #
Building Department � ,
J.J 362 {3 212 Main Street &� � � � �°
Room 100 ,E �
DEPT.OF�JitUiNG INSPECTIONS
Northampton, MA 01 060 ®, sr
NORTHAMPTON,MA 01060 PA,
phone 413-587-1240 Fax 413-587-1272 ,
. k u ter _ �. w 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 to be comQieted by office
C�l� r d 3Nla4 1 COI < m"U_t
[V}rte- ti In,ry ( � 'TV 'u Cit.�L� Zone Overlay District
I,v Eim St.District, „,...,,....:4,,,,-GBD�stFtct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner
/o-�f{Recordd:: ///� ���( (/ /�r// C , (\ /� /� � `/\)
tk Na , - 'nt)
Current Mailing Address:
��
Telephone j,ii i
Signature p \' � � 4 L-f `,
2.2 Authori�d Aqe'�'.
:S____ __.; . r� z[ /4-einifs / S _,
Name(Print) Current Mailing Address
(03 - 2/7 - �/,5 l
Signature Telephone
SECTION 3s- •TIMATED:CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building g 0 00 , 0� (a)Building Permit Fee
2. Electrical °Q (b)Estimated Total Cost of
1 � ;” ' Construction from(6)0007 A
3. Plumbing Building Permit Fee/ �� 1 �O
4. Mechanical(HVAC)
5.Fire Protection ,1
6. Total=(1 +2+3+4+5) /Of (rU oO Check Number
This Section For Official Use Only
Date
Building Permit Number. Issued:
/ �,—E —/
Signature: .` I.[_.� r
Building Commissioner/Inspector of Buildings Date
21 CHURCH ST BP-2014-0015
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 24D- 114 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category:renovation BUILDING PERMIT
Permit# BP-2014-0015
Project# JS-2014-000032
Est.Cost: $10000.00
Fee:$60.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: JAMES FINN 88014
Lot Size(sq. ft.): 5706.36 Owner: KRAWCZYNSKI JAMES PAUL&LOU A
Zoning:URB(100)/ Applicant: JAMES FINN
AT: 21 CHURCH ST
Applicant Address: Phone: Insurance:
21 HENRY ST (413) 584-4566 ()
NORTHAMPTONMA01060 ISSUED ON:7/16/2013 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL KITCHEN
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 7/16/2013 0:00:00 $60.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner