32C-291 DATE STORE AMOUNT PERSONAL BUSINESS ATM
AUGUST 2004
GH KICZA& SONS
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w DEPAR T ME1JT OP DUILDDNG INSPECTIONS —'
212 Main Street ' Municipal Duilding
Northampton, Mass. 01060
WOMCEWS CO\'Q'ENSATION MSURANCE :;I F A3 FIT
GZ�c-
()1CCl1Sx�(�rTJ]1(iCC) - - --
%vith a principal place of business residence at:
ln..C, (phone ') L
(scr�t/ci /sta-Lc�z�p)
do hereby certify, under the pains and penalties of pcgury, ?hal
( ) I an an employer providing the following worker's compenscDon cove uge for Ins'
etuplovecs wor�air)g on this job:
(lasu.r-:,o= Corsrsv) (Pclier NU-`ntr_r) ---- (T,pinion, Dar )
(No I am a sole proprietor, general contractor or hotneowDu (c cie one) and have hired
the coouactors listed below who have- the folloWmi g worker's c0M-ptnsahon Pericles:
(i�aSl]C Oi CO^.';:!Cl0"� � (�I1R?1�371C,:. COtilDlJl)'/�1 GUCi ?��1r'=1) Ct?:)lidl:QII ���tC�
(Name of COUTTZ! or) _ (1nsJrzflc ComDaIl,,,/P011c- Nu�crr) T�pir.cion Date)
(Name of Connaclo;) Omsur-anc; Compan}-/PoUcy N-amb:s) (Expiration Datc)
(Name of Contractor) a su=e-- Comp.?- y/Pohcy Numbr) Tx-pir-atiorl Da1r)
(.rl-]add?Uccal r'_xct irmc� r'.to axlud-tnform-zioo pcxtainins in.L
( I am a sole proprietor and have no one worldDg for me.
( ) I am.a home owner performing all the work myself.
NOTE:pl=s.-be aa-arc qj1 NJ.Jc bcmco D« utip employ pc T W d, sr• ?cz.-`'.rte,o cr rc�au •orx on.d..< ,-Z of
not most then tbroc tmi'u in kk-n6 Lb<botnoo,oc ida a co the vvjD,a z7purtcu.rs lscY a.-c w(cc:cnUv eccr dpi w be
employes unC--the t.airfz arIy ztioa An(GLI52.s I(5)�rgvticar6oa by a bomco -ocr far--bc5__or permit racy c.i&—thc
I cS-J crab-of an-=Ployer uo&c din Wockc,-,C.ompoasatioa A,,-
I uadcst.nd cb-x oc py of tlai,mt.cmom my t 4 foe xi rdnd to th.Dcporsaxai of]ad.wirJ A d std OE of lrc""°o°
eovmib�c vaiGr�tioa a.-td tlLt L•il�e to tonare bovernse tsdcr section 2 S A o(hfOL 151 can lad w the i�iliw o(ciminaJ pcoaltin
coaziri o(a fine of up to S l-5OO.00 andlor at>prjsocm�orup to one Y.,_.d o�i)pm.JUO in tic form o(a Stop Wock order and a
rim o(SIDODO i day tpina cor-
ror�A'�'=�u.c only
Pcrmll Number
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5T DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building
�1M Sy
Northampton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction sup : ,-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
divelling, 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 rqoesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date CK
Address of work
location
Signature of Owner/Agent Date 3
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor; Not Applicable ❑
Name of License Holder:_ ��o 2_
License Number
CJ U 3t
Ad ress Expiration e
(o
Signat Telephone
9.RegisteredrHome;Ir>hprovemeint Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 30=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....... ❑ 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
SECTION S-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Alteration(s) ❑ Roofing ❑
Windows Or Doors ❑
Accessory Bldg. ❑ Demolitionk New Signs [ ] Decks [ ] Siding [ ] Other FL*l
Brief DescripAion of Proposed
Work: ('d'n.at' �nS "C Lnf 0-"CL / O4
Alteration of existing bedroom Yes ✓ No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes ✓ No
Plans Attached Roll❑-Sheet❑
..4: F Alit:Ekt� Sd:B tf Dt~ d�E ECft>E:#Q: iSifl''CJ:#1Oti5 .�tACrI$f#CYY ' t #fI�Q1fif#i�7ft
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 .
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject
property tl
hereby authorize Ci e_o�4 e- �A C'2,0-- to
act on my behalf, in all matters ative to work authorized by this building permit application.
c� a._ s�
Signature of Owner v Date
I, e�'�`) A i C as Owner/Authorized Agent
hereby declare t 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.
Print Name
w
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
parking)
#of Parking Spaces
Fill:
(volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO y DONT 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 DONT KNOW
YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issuued:
C. Do any signs exist on the property? YES NO J
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:
Northampton
DR
i SL j Department
x
1 Main Street o
AUG 3 - m 100
"lo m ton, MA 01060 M"111,11,17,
.�
- 87-1 40 Fax 413-587-1272
OF t I, p IO�f
DEPT 0. 911 lD NG_�S:ECT S
n N far VA 01060
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1,1 Properly Address: This section to be completed by office
MaP, ,Lot Unit
Zone Overlay District
Eim st.District CS District
SECTION 2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
ame(Print) Current Mailin Address:
---- � V-- 0 976
Telephone
Signature
2.2 Authorized Agent:
GCpNe �1 . K4 C,?Cu 1.49 M b4eb- vv -u .
Name(Pn Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 5"G� (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) Check Number
�n This Section For Official Use Only
Building Permit Number:�/�SN��""� Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0140
APPLICANT/CONTACT PERSON ANTOSZ EDWARD&ADELE
ADDRESS/PHONE 34 HOCKANUM RD NORTHAMPTON (413)584-0970 Q
PROPERTY LOCATION 34 HOCKANUM RD
MAP 32C PARCEL 291 001 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
Typeof Construction: REPLACE EXISTING 6 X 30 PORCH FLOOR
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License 084268
3 sets of Plans/Plot Plan
THE F LLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 Commission
V/ 00�
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.
34 HOCKANUM RD BP-2005-0140
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:32C 291 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildiinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0140
Project# JS-2005-0153
Est.Cost: $2500.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: GEORGE KICZA 084268
Lot Size(sa. ft.): 6185.52 Owner: ANTOSZ EDWARD&ADELE
Zoning:URC Applicant. ANTOSZ EDWARD &ADELE
AT. 34 HOCKANUM RD
Applicant Address: Phone: Insurance:
34 HOCKANUM RD (413) 584-0970 0
NORTHAMPTON MAO 1060 ISSUED ON.8113104 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE EXISTING 6 X 30 REAR PORCH FLOOR
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:
Row-h: Rough: House# Foundation:
Driveway Final:
Fin iI: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Fin:i 1: Smoke: Final:
TI,IS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Ce,`ificate of Occupancy Signature:
Fec yDe• Receipt No: Date Paid: Check No: Amount:
Bu:' 'ing 8/13/04 0:00:00 1183 $50.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo