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29-169 (2) 't 4'CtV►A1P�. 19 1\.. Gritp of Nart4ampto t r p. w y � �I A368C}'1lSttt4 ' s DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municipal Building �'°�., S`•y. Northampton,MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CNIR 108.3.4 to act as h-is/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 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 FSttnxrTO °�?�_ of \Ia rtljctllt}tft1tt 6 �1�[SS RClt tt6Clla DEF'l1t2TMt"•A'T OF BUILDI)�G INSPLCTIONs 212 Main Street ' Municipal Building j Northampton, ?Hass. 01060 WORKER'S CONITENSATION INSURANCE AFFMANVIT _v- v"Ith a principal place of business/residence a-. (phorlC71 do 11creby cerL1ly LI1<' :1- Ll1G' h iIl$ :'.ii7 1)Cil 1LiCS Chi pC:rlury, "Im" I am an crnp!oyer providi11, the follov.,MC v Or'r;Cr`S C0I11pCi1SnoI1 cove["a`',e f0r trey employees worldrig On dies job: (I»1ranc- Corap:m,) pir:don Date) ( j I am a sole proprietor, general cc11!=c`cr hoc-,oO Der (cc,-Cle one) and hav'- 'tired the contractors IISteC beiov.,.x110 the `Oils, .Lj Z, ttlOFke,`S GOI peII-,.2101, ('`:a_MC of COtitrlCtGC) (1115 ti.1CC LO1P.^?:i'ji1 GIIC{ ?1lISIl i) T?: r<": C'�atC) (Name of ContT-=,or) (1.1LSlI iP.0 COmr�2;iviPohcC, Numb,--r) Date) CNIame of Coatractor) Ins[:,Ix Coiy ;_n•;i?o!ic- Nujnr,�r) x;,sr:coa Date) - 'Name of Cont actcr) —- (Iasi rane Come } Policy Ntlml; *) (F:xr;i�:tic- Date) a-m a ,;Ole propTi "oi Z: ili?V 110 OI1 U?" ii` t0; DI } I ?ill a home 0vym1 i)Ci-:0`1111I'` 11l ?i0 rl::plwsc tY I.S�Z:G t}:�:'.il;}c 4,c<:cv�ti�r_-:��-�c.-.pl�-�•;r.-::-::::n c::��:;-':�nc4 a::__n:�.:m cr:ri;air��•:;,r-;_4��c1?i',c: not uxYe than thrco wins in ut et he f rz.;.iz -rr:,:cz C'C a; ` •:._i-�v r ee rt Lhce o c c x<Ccrrzliy cc .::::_:: :c cmploye.3 uz.:er the wcti; c cc x-,:e:i^n Ar (Gi.15�, -! ill ^„ic:;by or p:fa:i: u.- lep[ct�wu of as ampioyer un&er'Ln Wcvkclx oz,r.tion^.ci- I undciztxnd th,<t a copy of th n ctatar-.cat f::..y b,fo v nfdo l to::o IYtxi t rn of Lod, triJ A4ci&n y Of —of for U. covcrn&c veri[jt~ticc And that failure tot ,c,:�irla 25A cd MCL,152 can Icnd to the irnposilion ct r. ^i_1 pct:nl;::s comixting of L fmj-of up to sl,5 00.00 a-d'cr -1 of::a to era}-u e'.1 civil xzuttia in tic f<,nn cf n Stc, nY.<}�' erA fl-Mc of 5100.00 a dsy For d r—utrsCal c ccly 1 Si zj tjrc of S�CT01�8� COISTRUCTION SERVICES 8.1 Licensed Construction ervisor:/ Not Applicable ❑ Name of License Holder : License Nu er 7, Expiration Date Signature Telephone .�rernen Im n .a. Not Applicable ❑ r. � Com Name Registration Number r AcWres Exp(at'on Date Z2q Telephone SEGTIOI O&,.,QRKERS' COMPENSATION 1NSgURANCE 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 buildine 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 • s IRNM GNSOF�PROP�OSED�WGRK checFc f(a lica 7e SECTIONS,. S P New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ J Siding[ ] Other [ ] Brief Description of Proposed Work: c� Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes No Plans Attached Roll 0 • Sheet 0 a a:e =o if on4R0 ex sting 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 EC O lAf ER�U FlOiRIZATION TO BE COMPLETED:VVIff MI O 'N�ER � O ONTR�ACTOR APPLIES FOR BUfLDING PERMIT. I, S� <� P�� r ' '✓ ( as Owner of the subject property hereby authorize to act on my behalf, in all matt s r lative;ty,%oWauthorized by this .building permit applicatio . Signature Ow 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. Print Name Si ature f 0 ner& Date Po- % 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 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 IF--YES, describe size, type and location: jolnrO Northampton g Department Main Street oom 100 pton, MA 01060 240 Fax 413-587-1272 DEpi Or B ION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE IN,FORMAT10N This sectio"#o Li`" mp,Fete° �byffic k 1.1 Property Address: �3 ON R 1-11a a ' Q 1 6 EIm�St�Dist'nct CB Discf ... _.: SECTION 2- PROPERTY OWNERSHI_P/AUTHORIZED AGENT 2.1 Owner of Record: %mac Name(Print) Current Mailing Address/ g Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: Signature Telephone SECTION'3.- ESTI MATED CONSTRUCTION_COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by ermit applicant 1. Building ,. (a) Building Permit Fee 2. Elea rical (b) Estimated Total,Cost of Construction,from :5 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection OQ 6. Total =(1 + 2 + 3 + 4 + 5) Check Number This ` Section For Official Use Only BuildingPermif Number: - fSl�� ld / Date Issued; Sagnafure: Building Commissioner/laspector-of Buildings Date r File#BP-2b04-0104 APPLICANT/CONTACT PERSON Ronald Mistarka ADDRESS/PHONE P O Box 205 (413)575-1271 PROPERTY LOCATION 80 DEERFIELD DR MAP 29 PARCEL 169 001 ZONE URA THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out Fee Paid 7,270 A SO Typeof Construction: REPAIR SILLS&PLY New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 069836 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 Commission Signature of Building Offi ' C41 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. BP-2004-0104 i a <X GIS#: COMMONWEALTH OF MASSACHUSETTS `29=t69 CITY OF NORTHAMPTON Lot:-001 Permit: Building Category: BUILDING PERMIT Permit# BP-2004-0104 Project# JS-2004-0168 Est.Cost: $7000.00 Fee:$50.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: Ronald Mistarka 069836 Lot Size(sq.ft.): 32931.36 Owner: BRACKETT STEPHEN J&KAREN A Zoning.URA Applicant: Ronald Mistarka AT. 80 DEERFIELD DR Applicant Address: Phone: Insurance: P 0 Box 205 (413) 575-1271 NORTHAMPTON MAO 1061 ISSUED ON:814103 0:00:00 TO PERFORM THE FOLLOWING WORK.-REPAIR SILLS & PLY 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 Sienature: FeeType: Receipt No: Date Paid: Check No: Amount: Building 8/4/03 0:00:00 1489 $50.00 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo