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�, DEPARTMENT OF BUILDIJ\'G INSPECTIONS �>
INSPECTOR 212 Main Street • Municipal Building
North,unpton, MA 01060 ,
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as i-.is/her construction sup,-'., ,, 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 backfiIl),
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, �,�1. / /ti J t /�/ J/� �� 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 7 Z7`—
Address of work
location j & Z1V 0/–'
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Oy _
F ti �Z� t7f �,TIZjfIji3111ploll - —
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Q DEPARTMENT OP BUILDf)\C INSPeCT70T:S
212 Main Strcct 2sfunicipal Building
Northampton, Mass. 01060
I
W O11.14:iZ'S C O 1MT ENS ATIO N l:r`1 S URAN CE Al, , A VIT
(tic=&& permittcc)
v.,ith a principal place of business/residence at:
(ph one:=')
(S07=t/ei ty/stale!p)
do hereby certify, under thc.pams and penalties of pcg'ury., hal
( ) I arm an employer providing the following worker's comoens-nDon coverage for my
etuplovices %vor-aog on Oils job:
Qnsv.==Comp=y) (Pclic; 1;1--zb--r) F- iruon Dam}
O I an a sole proprietor, general coatraaor or homeowner (ci cie oee) aDd hzve hired
the conSadors listed below T,rbo have the 'OLowinQ Worker's compensation policies:
(i+t11i1: O. Cone nc�o'1 (InR rant Comoan)'/PGUci Ntuj-ni•r;) C)t J Qn bale)
(Name of Conmaor) (Lisura.nc-- ComoanyiPoUm Nunb^r) (—Ex-Du uon Daie)
(Name of Contractor) (Lasurancc Comnany/PoUq- Nurstkr) (-xpLmrien Daic)
(lame of Contractor) (Iasumc—c Comcaay/Policy Numbzr) k—txp m6oa Da1r).
(am2cb-ddi::ocmj 6'eet if nex--v to C�c!%Id--mfoem=oa penaiaiag w.0
{ ) I am a sole proprietor and bave no one woridng for me.
I am,a home owner performing all the work myself.
NOTE:plea be cwwt tbx kirk bcco=w-3 wbo ctaploy p.=tans tn di crrae,uo c rrsir ,ocX w.d•ell^Z of
aoe moct the Lbtt uaiti in u3icb the bomoowoc raid=or oc t.be A-o%.�xpput • the2.n e. aoc C.a:.11;+oeerd and to be
c¢¢roy--ttnl +the--- c{T ar *=L:,•on Act(GL152=1(5);,spptua.00a try a bom.00wo=kr c lice-a rxrmi =Y`6 t
Icgz1 M=u of as c=ployer uodar dap WockxeL Compomatioa Ad-
I u-dc- tha>Dopy of tb6 cat—ei my tae for�r to the Dopnrcmcca of(ndaur..id omoe of Iraur� for the
coV-1-zc veircRioo Wnd ttu G..iltac to Leai= md=s,Cu a 25A of MOL 152 c=led to the i, IItoa of eimias!pc>Z+16=
000usiag of a fine ortip to T 1}00.00 and/or isaoz> t o(up to Doc yr3r end ei�i1 pm.tie n 6c form o(a Stop Wor{ Ord-and■
fim 0(5100.00 1 cLy tpt=me
For dW�'1,t use only
PCTTD.iI t`111.tI]t)CS bo r
Sipant�y�of LiSCClPctmiucce j
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
g..Re4isteieci°1.7ome�maiovement�Gari'tFac�'�orT: _��� ;� ��` '.�.,,�� Not Applicable D
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MG.L.C.1'52-,,§:,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...... ❑
lr11Yene' }
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) E Roofing El
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks Siding[Other[E7]
Brief Des ton of Propo ed
Work: +A a eZL/Z
Alteration of existing bedroom Yes No Adding new bedroom Yes /� No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
saie [ioeise a rclifFOro exlstirltou rt
mDie�eie� owticl:
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 Cons,.;ervation Compliance. Masscheck Energy Compliance form attached?
In. 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-;OWNERAUTHORIZATION TO BE COMPLETED-�INHEN
OWNER3:AGEN OR'CONTRACTOR:APPLIESFOR BUlLDJKG PERMIT
as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
�G��l�� ,as Owner/Authorized
Agent hereby declare that the sst tatements 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 ,
Date
Signature o Owner/Agent
'
. `
Section 4. ZONING Al I Information 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
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bIdg&paved 11-7
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Variance/Fi nd i ever been issued for/on the site?
�� ��
NO "0M� DONTKNOVV \_� YES �~�
IF YES, date issued:!
IF YES: Was the permit of Deeds?
'
NO K ) DON7KNOVV YES
��
IF YES: enter Book Page and/or Document#|
'
-�� x~�
B. Does the site contain a brook, body of water o,wetlands? NO V0� DONTKNOVV x_� YES
IF YES, has permit been or need to be obtained from the Conservation Commission?
Needs tobeobtained ��/�-) Obtained �~\ Date�~� '
��
C. Du any signs exist on the prnper�? 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 _
IF YES, describe size' type and location:
E. Will the construction activity disturb .grading,excavation,or filling)over 1 acre cxis it part cfo common plan
thowN|disturbnve,1aore? YEGK � NO ���
�� ��
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton
—Building Department
r n 112 Main Street
Room 100
Northampton, MA 01060
<<„ T190013-IU-1240 Fax 413-587-1272
APPLICATION TO CONS'bRUCT,'ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1,-SITE INFORMATION
This sect►on to be co[npleled byoffce
1.1 Property Address: �, s�
Ir h VL�i t5 llGtlt
LTt+)fl � � OS/e�a�l�FStfC1Ct
Elm S>»fi1�stGict c .., CB,Dastrct =.:A
.SECTION2-PROPERTY OWNERSHIP/AUTHORIZED AGENT'
2.�1/�Owner
)of Record: ]�,p ) / /� p] j( % /��g �l�[j� Jam/
YY/jkH )1JM-k yAV 6!( La/ /VJ /� / 22 6 /t (J i5 / 19 // &DI-
Name(PrintL t Current Mailing Address: Z/—A -2 `S--
t. Telephone f
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION!3-ESTIMATTED7 CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
co leted by ermit applicant
1. Building ,�'1 /`1 i1 G� . ),Building,PermitFee
2. Electrical (1 (,/(,� (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) Check Number S
This.Section-.For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
BP-2007-0076
GISc#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2007-0076
Protect# JS-2007-0121
Est. Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 3005.64 Owner: BLIZNIAK NANCY J&WILLIAM J
Zoning.URC Applicant: BLIZNIAK NANCY J & WILLIAM J
AT. 1 KINGSLEY AVE
Applicant Address: Phone: Insurance:
122 CROSS PATH RD (413) 584-8225 ()
NORTHAMPTON MAO 1060 ISSUED ON:712412006 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL REPLACEMENT WINDOWS, SIDING &
GUTTERS
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 7/24/2006 0:00:00 $50.002453
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo