35-021 i ii
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DEPARTMENT OF BUILDEVG INSPECTIONS
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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 iiis/her construction sup,: ., :,or. T lie state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fami _
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 ftgulations. 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 unt' such time as the proper permits and inspections are
made TD `
I --, understand the above.
(Home owner/resi en 's signature requesting exemption)
I will call to schedule a quired building inspections necessary for the building permit
issued to me.
Date
Address of work
location
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F E Crif Qf ;c�rf(Jaiii�to�l - _—
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ca DEPARTMENT OP BUIL.DI)\10 INSPECr(O1.'S
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212 Alain Strcct ' Municipal Duilding
Northampton, Mass. 01060
wOIUCI:IR'S COMTENSATION MS URA.N CE AFFD)f ..Nrrr
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\Vital a prmi cipal place of business/residence at: — -
(phone.')
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do hereby certify, under the.p?-'m znd penalties of perjury:, hat
( ) I am an employer providing the followine!workcr's cornocnsadon cove age for my
etnplovees working on this job:
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QMsuranc Comp, y) (Policy Nt:mb-cr) (r:-pimvor. Dpr-)
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( ) I am a sole proprietor, general contractor or homeowner (ci c;e one) and have hired
the coo=artors Este-' below who have the follovri P- worker's camoep_aaon policies:
(i+amc of Contnaor) Gn uranc,;.Comoan}vPobc-; ,IutIlL-C-) ` xpu-juOn D.-IIC)
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(Name of Coar-aaor) MsuJance COMDa1}vPoIiCv Numc^r) Date)
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(NZ-MC of Coaa-aco,) (Insurance Compan)-!Folic}- N-ILM—kf) (Expiraoo Dalc)
(Name of Couaacior) (Lasura.nc—c Comr�y/Policy Numb r) (Expirdoa Date).
(aII.a� .,u:�or3.1 t'.ccc.if arm-ta mc?ud:iaroccu:ioa perrniaia.s to.11
O I am a sole proprietor and bave no one working for me-
1 I am,a home owner performing all the work myself.
iNOTE:pl=zc be aw2m tt,. .t Je bc,, oa,., to euiplay pezam w clo = cszaju a r rep:za WgrjC oa L d..elLZ of
a.ot mete th:a t,4w L-Urj in«'.adz Lb.bomoo u=roido or oa the�ounc:.zpp�tbee z-c ox C= zlty oL=.d-td m be
eizployc s un a the Wes: ., Aa(GL!!SZa!(5)�ryptiotioa try a bommaoe fc c l ex__er prtnft cty c«dmoc[Le
loge!ctaau oraa erjloyxuadcrdso Work-(-C,ompom.lioa AA
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' l�ZSaa m.d x�.artb;,mt®�m.y�ro(-v.uded a tbo Depaetmena ari�.r,;�n�d�>'o>v�or tra.r.aoa r�r t6e
oovrzsc v aj f czliaa aad ttzl Ciluc to soasrc kovcrztsc ttadC-=C-a 25 A or MOL 1 S2 c=tcd m the L-N=ioa of rimiest pcaahics
oomzsszg of a Gee orzP to S 1 500.00 azldJOr ()Cup to ooc yezr eOd a,.zl p=eja in 6c form of a Scot,Wort;Order aad a
rim of S 100.00 i d_y pcia:a me
( For drys "�u,c only
. L (zcTAUt NUIDtKr Lot
Map-,-- �
Sip�atuic ofLi�scr./P rrn.iu e
SECTION 8-CONSTRUCTION SERVICES 7]
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
S hearsfered omen otav enec CFm radtor� Y` 1, , ��P^ Not Applicable ❑
Company Name Registration-Num er -"--
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAViT,`(M:G:L.c.152,,.§=25C(S)),:
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 Local Zo g ws and St of Mas chusetts General Laws Annotated.
Homeowner Signature
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑:, Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors E]
Accessory Bldg.5 Demolition ❑ New Signs [0] Decks [C] Siding[[--3] Other[o]
Brief Description of Propose
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes Y No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
.: 4 •.,.: aa-
Al rsx ��s.°mow: w ,MSµ?:°
sa �€Nevv-ttousertir l- d�tla o ext�t�il ioilsirlct,comp►et fhb a[f6Wlncl:
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
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 Ta-OWNER AUTHORIZATION-TQ BE_COMPLETED WHEN
OWNERS AGENT-,OR CONTRAGTOR.APPLIES FORBUILDING-PERMIT
el
as Owner of the subject
property
hereby authorize
trdpn my be a ,i II m�tive ut horized by this building permit application.
Signature of Owner Date
l J, Zut& �K f< , ,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.
Si ned under the(painss and�jenalties of per*pry.
�L1,(�Cpl 'V 2:�Aw�jlG
Pri N me
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Signature w Agent V o6te
Section 4. ZONING All Informati6ri 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 L:! R; L; R:
Rear
/v _
Building Height -
Bldg.Square Footage � E—I %
Open Space Footage % -- I--
(Lot area minus bldg&paved ,
I—_ w o
parking)
#of Parking Spaces
Fill:
(volume/&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW 0 YES 0
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW 0 YES Q
IF YES: enter Book F Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained 0 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 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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City of Northampton Sta ti
rauilding Department
1212 Main Street -
_,._ - Room 100
Np�tmpton; MA 01060 esottic�ra��i
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JUL 3pr4�� 41 8 1240 Fax 413-587-1272 F'tattSte 'tans ' �
,,, 'S.. .ptfte� iecifj�� .'���'��• . a � '�ic"."����r."'�.`$ '�'�s
�STRUC ,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address This sectionto be completed by office
F&A,1 ,C' uMa� Lot
. Unit
0 �� Zone OverlaykDisfnct
t vV` ,
Elnr S't.Dfstrrct `CB Distcict
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT:
2.1 Owner of Record: r
a e(Print Curt Mailing Address: 0166
c���sC;
Telephone
Signature
2.2 Authorized t:
Name(Print) 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 / 0a (a)Building Permit Fee
2. Electrical f (b)Estimated Total Cost of
Construction from 6
3. Plumbing , Building Permit Fee
4. Mechanical(HVAC) ..
5. Fire Protection
6. Total=0 +2+3+4+5) ; . " '` . £" Check Number
This'SectiomFor Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissionedlnspector of Buildings Date
File#BP-2006-0038
APPLICANT/CONTACT PERSON ZULAWSKI DANIEL J&ANN L
ADDRESS/PHONE 88 WEST FARMS RD FLORENCE Q 585-8680 Q
PROPERTY LOCATION 88 WEST FARMS RD
MAP 35 PARCEL 021 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
T_ypeof Construction: ERECT 12 X 14 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 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 mmission
0a
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.
88 WEST FARMS RD BP-2006-0038
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35 -021 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category:ry: BUILDING PERMIT
Permit# BP-2006-0038
Project# JS-2006-0056
Est. Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 67953.60 Owner: ZULAWSKI DANIEL J&ANN L
Zoning: SR Applicant: ZULAWSKI DANIEL J &ANN L
AT. 88 WEST FARMS RD
Applicant Address: Phone: Insurance:
88 WEST FARMS RD O 585-8680 O
FLORENCEMA01062 ISSUED ON.7119105 0:00:00
TO PERFORM THE FOLLOWING WORK.-ERECT 12 X 14 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: Date Paid: Amount:
Building 7/19/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo