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DEPARTMENT OF BUILDING INSPECTIONS ==r�
INSPECTOR 212 Main.Street • Municipal Building
Northampton,MA 01060 ,� s`,y.
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:,'isor. 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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DEPARTMENT OP BiIDING INSPECTIONS
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212 Main Street ' Municipal Building , ,-......., :
Northampton, Mass. 01060 .. ,..
IMP
W 0 RICER'S COMPENSATION INSTJIZkN CE Ailq.q_)AVIT
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with a principal place of businessiresicienc:2 at: •
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(sti-c,,,,ity,,,-.2::_,.,,,p)
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do bere.b certify; under the pains and penalties of perjury, that
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am an employer providing the Follow:km:. ..-,.orkerrs coinpcnsauon covera:.!.c for my
employees wordng on this job:
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(Instu-aa= Corn 3,:) (1-)ciicy Nurriber) (Expirn6on Dat )
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( ) I am a sole proprietor, zentral connamor er homeowner (circle one) and have hired
the cont-actors listed below who have the follov,i.nce worker's compens.at-ion bolic:es:
•
eN0,_Dac of Contractor) CLrifurznce Comp2:1-,./Potic:f N'urnber) t:17.) nt:or, Date)
(Name, of Contractor) (irisurancc Cc.,. cariviPoticv Number) (EY.T:Imi: 1 Date)
(Name of Coati-actor) (las-urancc CO E.37,.-E37,./1)o I icy Numb-an) ,,F :ranc-.-, Date)
(Name of Contractor) (Insurznez. Comr-al.:y1Polic-..,,, Num:r,er) (Ei:rpt r",:tiC71 Date)
(,. ,,d,..,.. 0(,i ,,-,--.,,,--„,..,..,:-..-.., ,r4--..::').:7::-.."-7,:r..::::.c.r-=',:r.;:l.;''..-.11,:cr.r.,:-'..-•;•
( ) I :un a polo prophe'. :- oad have no olie i ..;n.:- for me
( ) I am a home owner 1.-:erfcrininc, all [.._-:,- -..-•,,..- :
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No-c-F.:ptc..,..5,f..,-..a•A-Jrc that wth3 0 Frttnc-...),,-,x-,:a v,-,....D c-:-.72!:.-,7;,-.-.:-...::-7._:t.-)t1.) _ _"..2rIcc.,cl..-,:r.:..r.:c.--'_:c.v. --.1.'....,.:11.-..;
ricX IITCYC 1.1%-:0 throo uniti tr.wf.;:th',.:1‹il.,-..-.n.:•:...vr..rr:":-...:,!...=CA-CDC",S.F-,-;-_,_::-.^_.1 z.'7-::•_:.:',..,:r•-2.'....h.=-c.....:a::cr.:<c"..7rn.r:11y o:r.:-.C:: :.."...7.•tsc
c.r..1plor=r3 urx;...'cr the tvc:*......-e:.Mr.r....-r.r.r.:.f.v.:c:Ac (G:...152.ir.I(L):%nr--7:,::-.7.::ar.by t hiosyrscr far a L:c.:-_-_:c Cc c.Y.-.: :r.....!...r.--'s:rscc tha
Ice?!stxtuz of en act:playa<tuld.er tan Wecel Conzrorr..4.1aon.‘.ci-
I uavd.arst.uactl that a copy of this ctit...,...r.s.l.sr...y bo faINvrtrdad to W-,U.:part:1,a:of l.r,..str•rit.1, .oite Ca-too of!'-="r".:°for 1-t'
covertge.vc-ific-tioa:th.c1 that llilurc to!ee--trr.ccr..-rrt;-..un.:,:r::z.:-..i,:-.7.2 A of MCI,152,mn Iczai to the impositicel(,fr cr---1 pe-nali:=
c151i--1:i or.on,or up to;1O000.,==',a , ••.:r•sf..1;:,tr)cr.-.r.:.....r .:-.-1 civil pc:attic:In t c fl-mr,of:s.Ste-)`,Vc-A.C>r,f.=?..:-..t1 s.
fire.of 11;100.00 t thy si..;:ti !I mi-.
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to 7/703 ..; ,
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0 ANRUCT�C'ON SERVICES
8.1 Li ensed Cons ruc ion S •ervisor: Not Applicable ❑
Name of License Holder : �'�� 4 rs� _ Oa
ll License Number
Address 070-, Expiration Date
_ D
Si reir Te ephone
..Re t r `` s9 4aF; _ -. � � -. - Not Applicable ❑
Company Name Registration Number
•
Address Expiration Date
Telephone
SECTI `0 WO KERS'_COMPENSATION 1NSURANCE:AFFIDAVIT(M G:L. c. 152, § 25C(6))
Workers Compensation Insurance affidavit mus e completed and submitted with this application. Failure to provide this affidavit
will result in the denial of the issuance of t uilding 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 and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
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Ali •
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OP® tha.WaRK c ti
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
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• Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: a r _1 'AR• a-!j • i�i�
Alteration of existing bedroom Yes / No Adding n-w bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes ✓No
Plans Attached Roll 0-Sheet 0
a ew o n or a ilit.own to exrsti ngthoursi n?,= ar a e_ . lavwLrr
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. Mascheck 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
SECTiOro-Wki NrIER AU NORIZATION TO BE'COMPCETEI7:WHEN
O ,.A
WNER GEN7ai tONTRAGTOR APPLIES FOR BUILDING PERMIT'
I' • U A , as Owner of the subject property
hereby authorize — ;i//I i�i/.�% / /I�,i,I e ;t% jj J,J 104 ' / _ �y a" to ac: on
my behalf, in all matter rel. ive 1'� work authorized by t buildirrermit application, ✓
Sign of Owner Date / / ( �
I, � IOW".•� ' > / /..-,,f '. AAA IA 'JL��!iff 41 , as Owc /. uthorized Agent
hereby de are t at t - statements and info m ion on th- oregoing applica rn are true and accurate. - ------
knowledge and belief.
Signed 0 der the pains and penalties of perjury.
Aft
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Print Na e
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Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage
Open Space Footage
(Lot area minus bldg&paved
parkin)
#of Parking Spaces
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW
YES
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 NO
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ?YES ._
No
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City of Northampton . `;i,-1
.n.,,- Department s ,;,,,:.: ,,,,,,,_,...-.7.,
r l it M� L11:in Street
•t'I T �..._. �(J 100 „Av-4 �. -V may } l".A _ -_-_,_ _ _ _--
j Northa�r�r�� n, MA 01060 - . � 3 .
Torre 148 0 Fax 413 587-1272 �LLp`��!,,,t1" .
1PPLI( 45QI(I �,� Q�1S�`FltI1C ER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
°Th s SeCtl e a QITI e 4 a,-`
1.1 Property Address: " f.c
i / °I)V 7 Q-- -2-e-F llVlap��, ,� � --&
ZOne a.::3-°=:.z s OY @r ® St!' � '
a �iiiiA (ice z �I �� # ,3 $ a
y, '" G' "mot. . '*` r44:,,,,-:1,... ..,-,,-'
EIm.St District GCB..., riot �.
SECTION 2- PROPERTY.OWNERSHIP/AUTHORIZED AGENT
2.1 Owner/o�fi ecord: /n ( j ���/ � /�f
Ft
1)c e-f 1 L" 1 e l f- 4- r,& wi iW �f'►.0 K tom/
Name(Print) Currentff /mg Addr!��s: / /jic,
L_� /� �,�.,/ _ Telephone Cf/Q' t-YQ� w / .��
Signs�ire
2.2 Authorized Agent: �/���
r/��1�! r/�a /' .%/ hi ;i i /�6- I o2{1L- 37 "2 /�'<
Name(P ' / %' Current Mailing Address:C.9/ 5D .6E '2" 2
Signature �� 1 Telephone
SECTION-3 - ESTIMATED CO TRl1CTION.COSTS
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building
5 °9-j i (a) Building Permit Fee
2. Elec.rical (b) Construction stiated fro :Cost
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection j
6. Total =(1 + 2 + 3 + 4 + 5) (,77-r Check Number ���33 "mot,-'
This Section For Official Use Only
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
*Ni IP
File#BP-2004-0369
APPLICANT/CONTACT PERSON HAMPSHIRE PROPERTY MANAGEMENT
ADDRESS/PHONE 15 BREWSTER CT ,Sga-1970
PROPERTY LOCATION 11 CONZ ST
MAP 32C PARCEL 120 001 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 63,3S c ✓"
Typeof Construction: PORCH REPAIRS, SUPPORTS&FLOORS
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 070047
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF9RMATION 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
-/Z/‘/ 1 ii"---- O 2 200
Signature of Building Officia 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.
11 CONZ ST BP-2004-0369
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 32C- 120 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0369
Project# 3S-2004-0529
Est. Cost: $5000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: THOMAS KORYTOSKI 070047
Lot Size(sq. ft.): 8929.80 Owner: SHEMESH AVRAHAM&
Zoning.:URC Applicant: HAMPSHIRE PROPERTY MANAGEMENT
AT: 11 CONZ ST
Applicant Address: Phone: Insurance:
15 BREWSTER CT O 582-9970 ()
NORTHAMPTON MAO 1060 ISSUED ON:10/2/03 0:00:00
TO PERFORM THE FOLLOWING WORK:PORCH REPAIRS, SUPPORTS & FLOORS
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:Ck /U i'
• j'- - 0 3
J-`
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final: (}T 't d-7O-63
THIS PERMIT MAY BE REVOKED BY THE CIT a F NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 10/2/03 0:00:00 6333 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo