32C-182 (14) ¢Tt1AMP)O _�Q
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,a DEP.AaTMENT OF BUILDiT,1.G INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building
Northampton,MA 01060 S ,`
4
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CNIR 108.3.4 to
act as his/her construction super•,-isor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a one or tw6– gnu y
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 ui ing ep� menfioi the`City o-f Nortliampton-wants-airy-person(s)-who-seek-t-o _
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 r'_egulations. The inspection process requires that the building department be called
to inspect work at various stages, which include foundation/footings (before backfiI1),
sonotube holes (before oour) 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 occupancv
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,<R,n�4A understand the above.
(Home owner/resident's signature requesting zemption)
I will call to schedule all required building inspections necessary for the building permit
- issued-to me.
Date 1l 1a 671—
Address of work /
Iocation
A,
�/d66
SECTiON:8-CONSTRUCTION SERViCES
71
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
Swteatsteic >##onie fn?Q eirietaiit a
Not Applicable ❑
Company Name Registration Num er
Address Expiration Date
Telephone
SECTION 10-WORKERS'COM0.E9$/�TIdNUINSFl E�RNCEA�EIEf1�1ttT�Ntfcf..c.�5'2,.�•�SCEG�j.
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...... ❑
) ,
M ON
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 1083.5.1.
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,Sta and Local Zoning Laws tote of Massachusetts General Laws Annotated
4
omeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check•aftaoolicable)
New House ❑ Addition ❑: Replacement Windows Alteration(s) ❑ Roofing
�- Or Doors D
Accessory Bldg. ❑ Demolition I r! New Signs [0] Decks [[] Siding[p] Other[p]
Brief Description of Proposed
Work: [�C~!O e
Alteration of existing bedroom Yes No Adding new bedroom Yes _��No
Attached Narrative Renovating unfinished basement Yes ��No
Plans Attached Roll -Sheet
spa=F��(e �l ��n: '� `cd%�>.�i�o�:exs�>F���ior�sx�e co Fef��� fc�Ef g•
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
L 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 ACiI'K .RIZATION 'PTO BECOMPCETED:Q1(FIEAt
OWNERSAGE14,710 RCONTk7ACI.ORAPPLIESIi6kIb tILDII4Gkt'ERMI
I, 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 f Owner Date
I, 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.
Pri ame
Signa ure of Owner/Agent p
Section 4. ZONING All 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
Side
_ R:` L: R
L:
-- I
Rear
Building Height T-
Bldg.Square Footage % r tom,
Open Space Footage %
--
(Lotarea minus bldg&paved
arkin
#of Parking Spaces
Fill: r -
F
(volume'&Location)
A. Has a Speci I Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW 0 YES Q
IF YES, date issued:!
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES 0
IF YES: enter Book ( Pagel and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO �DONI KNOW 0 YES Q
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 Q NO
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
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,exqwation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q r NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
.... _
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTI6N1 SITEINFORMAT,ION
1.1 Property Address: This sectjdtuto be completed b offic
3 ? /�/j°� ,rrt�i� Lot Uti►tt
AVO,f,lr'y Ksr X o 0-ra 40 zor eN Overra}�Dcstnct A r
�EIrtrS�Elistrrct =< � CBD�stflc� � r
SECTFON_2-PROPERTYOWNERSHIPJAUTRORIZED AGENT
2.1 i*1 Owner of Record: 0�'r{.rZ/pl��r
AQ ,c�,K Syt 1°J 4, Sft ff,L' -f•; (sJtf ?�Y / /aC4J4gI-J�-rr • �/o ��clni � t�/a rL
Name P' ' Current Mail Address: ` 4/ JF
• Telephone Q (�
Signature -2 Y7 — q/0 6 �e�•�` �� G, a
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION'3-r ESTIMATED'CONSTRUCTIOk COSTS.
Item - Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)-Building Permft Fee
2. Electrical (iz 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 �-
This SectionFde.afficial`Use Only
Date
' Building PermittNumber .. :Issued:
Signature: r
Building Commissioner/Inspector of Buildings Date
File#BP-2006-0491 eA
APPLICANT/CONTACT PERSON SZLOSEK STEFFIE&PATRICK& �G��M✓�/�
ADDRESS,IPHONE 376 PLEASANT ST NORTHAMPTON
.day 7-�g/vo
PROPERTY LOCATION 378 PLEASANT ST
MAP 32C PARCEL 182 001 ZONE GB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid Nd `
TTypeof Construction: DEMOLISH ATTACHED GARAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION P SENTED:
Approved_V 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 mmission � � APL/Q�
Z
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.