32C-113 (25) SHPT , .(ritty of Northampton • )7 _u ,
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3 _,.-as:- DEPARTMENT OF BUILDING INSPECTIONS '� ___- /�
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060
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 sups.:" 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 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
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��Ir• DEPARTMENT OP BUILDrNG INSPECTIONS , •
212 Main Street ' Municipal Building
• Northampton, Mass. 01060 sr'
WORK E.R'S COMPENSATION INSURANCE AITDDA.Vfl
I, /4 y ✓ y f
(li ccusxJpcnni tics)
with a principal place of businessfresidence at:
C3/D S.3
/1/ 4/-,97- .8-z_ _z5--/—, 0e A.4, ' /.:2,15,.zerepep,r Aril (phoned) 58-1-' 7.5
(strr.a/ci ty/stai.cf p)
do hereby certify, under ttic.pains and penalties of perjury, that
( ) I am an employer providing the followintt•worker's compcnsahon coverage for my ,
employees worbng on this job:
.
(LnsLr_nm Company) (Policy Numbcr) (E,-pirtion Dui)
•
( ) I am a sole proprietor, general contractor or homeowner (ci ce one) and have hired
the contractors listed below who have the following worker's compensation policies:
•
(Name of Cont^cior) (Insurance Coroallyi?o Ci Numix:) (E::ptmuon Date)
(Name of Contrc lor) (Insurance Company/Policy Numcsr) (Expiration Data)
.
(Name of Conuacto,-) (Insurance arnpany/Policy Numbz.r) (Expirrtiea Data)
(Name of Contractor) (Insurance Company/Policy Number) (Expiration Date).
(an.Gh adu'„-ocal occt ifncoci«•to mc.1/414 tofonoo pc,....inizaz to di oxlc-_co:s) -
( I am a sole proprietor and have no one wor dng for me.
{ ( ) I am,a home owner performing all the work myself.
NOTE:plesc be..-..,it.':v.{ )c Ixmeow ocra u-tao employ pc-t-oct to do r-.%*?• rr, -.:.e�oo c rcpair wont on a.dwdline of
apt riot-tho Lb =its in tcbieh the bomoo -oo raids or on the crouckcil sppurtca:ct tbeeo c_'c ooc c-.71.....-:-.11y co ridaod to bc
c itployca■.r1r-the work e -ti---lien An(01.2152.to 1(5)).appticLooa by•bouscocvocr fc a lies cc permit tr=y evidmer tee
Icgs.l ctsn+c of no•-gloy• coder tho Wocicor'a Cocop-omu1»e AaL
I uaderss,nd tha a copy of thi.mss ta.y b.foe-,.ceded to the Dop.,nmm¢of lousier noodrats'Off oo of Ira• oee for th.
oovcrL6- vvrirenioa cad thin C-iliac to so urc'eoverase tnsdcr section 25A of MOL 152 eaa lcd to the invositioa of cimiasl 9- Itic
ccomizing of a fiat of up to S 1300.00 and/or iacprisoanocat of up to ooc yc r e.od civil pmat'ua io 6c focal of.Stop Work Or ..ad a
fun of 5100.00 a day.O ball me
For dcp.rtas'-1 u.c only -
i •
/ Permit Number
L2- G a L✓ J a y s'" i`cap Lot
Signature of %.!!. ,'traduce L� -- —�
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder: /Z-0 ' -✓ LAC-4,7-16/./
License Number
/1/Ae-.4 TE44- STS 6' 'i"7.k / z r-c's 0,,495 3 5// 2/d,
AddressssJ Expiration Date
iii - 5 %- 4/ -7S7�
Signature Telephone
S:..Re a liter lrOnt'e t a eO a doWti' r ° ' '
��trar o �:� � � Not Applicable ❑
Company Name Registration Number
7//Oj0-6
Address ,// 6y�,T rye ��- �'o ��u)Z / ;�-� Expiration Date
4e' 5, 4;,/ / o S Telephone '11 . _I a-1-9?Jv
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 0 No ❑
-;tit" ffi Wile �� t 8 15
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
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) Q Roofing EJ
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [CI Decks [L Siding[0] Other U541
Brief Description of Proposed �rir
Work: je....?/+ Oe i- Dyn/.✓.bcAii / 4xy7 -7 S r�/��� t."4,1 IG'I1-9, 4.x9.71/.%ZG'i'�"->"i,- s-,+(J,�°41 z, ante
-Z, .4,-,,,-0,44-.e. x,12 at el" '' v 1.i/J aaWv Alt 7 A S rl of,„fie -v,v4!s
Alteration of existing bedroom Yes No Adding new bedroom Yes No Q,f17.44/e-1, T
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a_If$Iew o Usa a� ct tia%ta axis`iic of s ct on fe ft ottaai i>Mt
a. Use of building:One Family Two Family Other
b. Number of rooms in each family unit: Number of Bathrooms
c. Is there a garage attached?
-
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
i. Is construction within 100 ft.of wetlands? Yes No. Is construction within 100 yr. floodplain, - Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN`
OWNERS AGENT:ORCONTRACTOR APPLIES.FOR BUILDING PERMIT
m& iv ,2J'$/Z j._ ,as Owner of the subject
property
herebyauth• e AA/2/A_ �, -7 >/f^ i�cf-e/
to act o behalf '• afters r iv to work authorized by this building permit application.
S Ore of Owner Date
I, 24 /t a. V -T YI'y%SCj/ ,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. '
Z/9 vt. y S tf,e4'2--- 561/
Print Name
e7 8 , . -.
Signature of Owner/Agen Date
ax .A.
Section 4. ZONING All Informatihh 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 1 I ---1 i
Frontage 1 ' l
Setbacks Front I I
Side L:4 R L:' : R:=
E ! ]
i
Rear
Building Height ,
i ;
Bldg.Square Footage r i % I 1 ,
I i _
Open Space Footage %
(Lot area minus bldg&paved ( i 1
parking)
#of Parking Spaces
Fill:
(volume,&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 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 i Page: and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW Q YES Q
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 ® NO 0
IF YES, describe size, type and location: I //?,2- 54 Lpr1.5/b4 '5w�e--J C'Ir e. 4' j, ,,i4r
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location: 1
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
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
r ' it,,of �'It �mpton St rt x
212'; a ri Street a
Robt 00
4�,�� L005 �./ fie '
J L JUL Northampton; A 01060 Se o Suet a
phone 413-587-.'140 Fax 413-587-1272 Pto Se ns
Jr� �� eae i',;1`,=.0. th �•£ l ' �.« � ` et
APPt�IfATlt7N TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1.-SITE INFORMATION
1.1 Property Address: _°
Th►s sect►nr►to be completed 6gotfEce
9 Cr[7 _Cr =d.- -J Mep l of UF#
x
bet, A (/yl /P '/F 6 Zone x Overlay D►sfrrcf
ElinSt District CBpistnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Pn l� Cady 4 <c,-" 1`1 �'��//J �7'fZr�r� �''/l ice,
Name(Print / Current Mailing Address: DfY�(� ��„Ii ,::::,...iiiiit
Telephone
Sign
2.2 Authorized Agerit:
,�zez�/ yr�"ivT SG:Ft /// Gr//,E 4E, 5l 1 �� f3�1 v m,q c / �s
Name(Print) ✓/ Current Mailing Address:g-F Signature U Telephone
SECTION 3.-ESTIMATED-CONS TRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit 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) p 6-'&4%. > �� Check Number ii, ,P , 7O v
This Section For Official Use Only
Date'.,.
Building Permit Number.' Issued:
Signature:
i
Building Commissioner/Inspector of Buildings Date
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File#BP-2006-0105
APPLICANT/CONTACT PERSON Larry Yentsch
ADDRESS/PHONE P 0 BOX 120 LEEDS (413)584-4750
PROPERTY LOCATION 59 CONZ ST
MAP 32C PARCEL 113 001 ZONE URC
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid QP-'—^
Typeof Construction: REMODEL HALLS, SUNROOM,BATHROOM&LIVING?►�
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 048666
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION 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 Co ion
7 Z151 200.c
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.
59 CONZ ST BP-2006-0105
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32C- 113 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0105
Project# JS-2006-0157
Est.Cost: $20000.00
Fee: $100.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Larry Yentsch 048666
Lot Size(sq.ft.): 12893.76 Owner: HEBERT PAUL E
Zoning:URC Applicant: Larry Yentsch
AT: 59 CONZ ST
Applicant Address: Phone: Insurance:
P 0 BOX 120 (413) 584-4750
LEEDSMA01053 ISSUED ON:7/29/05 0:00:00
TO PERFORM THE FOLLOWING WORK:REMODEL HALLS, SUNROOM, BATHROOM &
LIVING ROOM
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 7/29/05 0:00:00 $100.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo