29-264 (2) r
�Il A44AC�(714ltt4 -
�-, DEPARTMENT OF BUILDING INSPECTIONS
IONS /=
INSPECTOR 212 Main Street • Municipal Building
Northampton, MA 01060 ,
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:-,,i 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 backfill),
sonotube holes (before hour), 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
t 7 �
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6 !i�cssxchnsrcte ' _
DEPAJ2TMEI\'T Of' BUILDING INSPECTIONS
212 Main Street ' Municipal Building 'o
Northampton, Mass. 01060
WORICER'S COMTENSATION INSURANCE AFFEDA IT
v,,Ith a principal placc of businesslresidence is
------ (phone'=1 - --
(StTC°UCltr':S"t 7)
do hereby Cer-LLIV, L'Ilatr the pa:iils aucl pe lLlc s Oi p;;S�1111 !.I1;I .
I aSLl an. erllployer piOvidirl, the 1'0110.;ln. _. '.':Or:Ci S colllr)emsauon Cover2llC FOT Illy
e1uployees working on Llus jab:
(1DS`1ran�CoIIlPIDNI) [PC 1C;1`til,b--r) (FCxT,!l :don Date)
j I a.nz a sole pronnetor, .Teneral c-:)na a-or o homteowoer (circle one) and 'gave hired
t.lie contractors listed 5eiov-; v,-:o In2v, }ht it- y;,� .; e � ^l;c
t o�� •� orri scot., pen;k.�on
(- :LIZIIC Of r'On[IICiG') (I-rlsu nc. Cc,In?":;i !To(!Cj NUS71�--r) T?"' .3..1C' Datc)
(Name of Cont?-actor) (Zi7Su Ilce Comca.vfPolim, (E)Ti^iioa Date)
(Name of Contractor) lI1S� 3I1C' t 0ID':'_il:i%i�01;C: 1 IIII]li r) S.S it Datc)
- (Name of Contractor) _ (InsZ r�sic Comr,<_y!PoUcy Nlmri rr) (E;:ni :iio:Date;
tr!Lldt:-4�"�3uCY:1I S::Yt`• n^�..a^;�,�:�..V..,:_-...:_4:::a::Ci:-::'.:..: -,..)
l Z iLTl I: ole l)!Opr1f tC)i iiil havC no OIl i'Or�.Aii` Io1 ille-
� I rIl ? holl7C 0111V!1C" iiCi-:C"1?1111: Ill
?:O-CFi plecu be a:va:c L:;:-s�•ile Ixv-cv«;r_::urJ c.:-,�1-�;;x-,�;,�;::;-��•-•;;anc�ar::�-��m cr:r;�ait�c,r.' -..a�«cl!i:::,c.
not:nett LI>•.n tht'ce ttni'�i^:���:iett Lhc f-..r.:i�;u-tr rcai::�or a;�u ;;:i z ��rtcr.:r1 Lhcfo-:c rrZt
cZ'.Ployc3 urns the tvcri:r s arT-� :m ats (<�t.I53 -!(Sl?.a •;iic;:iv hot o:vncs fur t Cc= a Fcra:c r. ...'tirtie ._
Ics'l ctatuc of an csplo)w uodtr t::t)Wcviccfc !4.cL
[uadc-toad th>_t a copy of thi, cut--=rzuy to of i:::+.lr>?:e for tI-
covcrlgc vcziacatioc and ihst C:hue to -uc co�-r�ut c�,iM 25A of MC-L 152 can[c--d to tlx izirv�titia-t rr-i:._1 pail:a
<vmisti tg of a Cur_of up to S 1-30().00 mns.'cr ir:nr;u z�:•1 of t:P to cn-}u r.:.j civil pcnzltio in do Icx:n cf a Sic-.,';`c is Oti=to 1
Lr>r of SIQa.00 i dty ipiwA tn-
Fcr< ;aru:rttl!uro ally
/ Pcrrnit Nttuttz:r _ _____
! nature of i _ctJPcrnlittc, T','
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SCT�ON!8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
i9Resfeeti orne rrrpiovein'entContractor Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 WORKERS' COMPENSATION IN WNCE:AFFIDAVIT(M:G:L.,c. 152, § 25G(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"homeoNvner" shall submit to the Building Official,on a form acecptable 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 far 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 d Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature �/�i
SECT.ON S' D S , 1P�T ON 9Ab4 O i&*0RKAheck all a I�caiile
tt
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. -1;L, Demolition[] New Signs [ j Decks [ ] Siding[ j Other [ ]
Brief Description of Proposed Work—;:�u1 1I) A 5
Alteration of existing bedroom Yes _No Adding new bedroom Yes No
Attached Narrative D Renovating unfinished basement Yes No
Plans Attached Roll O• Sheet❑
a f �.e�, use a.:d a ci�.it on to eZ<isfing4liousing�co plea he follow h
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
SECT�ONT YV�IER�l7 ;ORIZATtON TO BE COMPLETED WHEN
OWNES ECONTRACTOR APPLIES FOR BUILDING PERICIIT
as Owner of the subject property
hereby authorize '�—I>E rT to act on
my be alf, in,all matters relative to work authorized by this building permit application.
S nature of Ow Date
l 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
Signature of Owner/Agent Date
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CrzfLl of 'Wart1jum itoit _
e AIR 5%R(11 It 6[t10
K {� DI'PARTAfE N'T OF BUILDING INSPECTIONS �+
INSPECTOR 212 Main Suee( o Min ic;il),l
Ncu-(hampum, MA 01060
.,w
MUST INCLUDE:
Site Plan I'lot Plan - showing all buildings with square footage and
Distance to property lines.
i. ential - 2 sets of frat plans(with smoke detectors marked)
addi a bedroom, floor plan of existing house with
\, i up smoke detectors
C�7mcrcta plans with fire narrative
Filing deadline is Wednesday by noon
Reviewed ev er•, "hhursday
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: ,cr
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:
f
City of Northampton
Building Department G
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587.1272
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
This section to bexcom Fetedb�office p
1.1 Property Address:
MK
Elm_St District CB District .
SECTION 2 - PROPERTY-0WNERSHI:P/AUTHORIZED gGENT
2.1 Owner of Record:
' ����► n `Z'A jN (.�
Name(Print) Current Maili, Ad ress:
� . (a 5�
Telephone
gnature Al
2.2 Authorized Agent:
Name(Print) Current Mai!ing Address:
Signature
Telephone
SECTION 3 ESTIMATED it RUd.TION'COSTS
Item Estimated Cost (Dollars)to be Official Use Drily'
com feted by ermit applicant
1. Building
(a) Building Permit Fee
2. Elec.rical ..
(b) �:aimated 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 3
This Section For Official Use Only
Building Permit Number:
Date:.Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
t
File#BP-2004-0496
APPLICANT/CONTACT PERSON ZAJCHOWSKI MARIANN
ADDRESS/PHONE 76 LONGVIEW DR (413)586-6965 Q
PROPERTY LOCATION 76 LONGVIEW DR
MAP 29 PARCEL 264 001 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 A:13 025--
Typeof Construction: ERECT 8 X 10 SHED
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 11P16C WING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF,RkMATION 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 Commiss'
a o X23
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.
76 LONGVIEW DR BP-2004-0496
GIS#: COMMONWEALTH OF MASSACHUSETTS
`:° "t,29-'264 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Cate,q�orv: BUILDING PERMIT
Permit# BP-2004-0496
Project# IS-2004-0705
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 19994.04 Owner: ZAJCHOWSKI MARIANN
Zoning:URA Applicant. ZAJCHOWSKI MARIANN
AT. 76 LONGVIEW DR
Applicant Address: Phone: Insurance:
76 LONGVIEW DR (413) 586-6965 (�
NORTHAMPTON MAO 1060 ISSUED ON:11 110103 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 8 X 10 SHED
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: Receipt No: Date Paid: Check No: Amount:
Building 11/10/03 0:00:00 1033 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo