35-063 p4�tiAMP�o
t
�IASSACI�1LSCttS -
DEPARTMENT OF BUILDD`G INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
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 supc:-.,iasor. 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 roueh 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 I o/,-,�zwz I/
understand the above.
Home owne sident's si ature equesting exemption)
I will call to schedule all requir d building inspections necessary for the building permit
issued to me.
Date
Address of work
location zu
j
01.1..-�..\
6 �i:i�iS7 R(ll{SSCt1S
rs m 1>EPFiiRTMENT OF DUILDDJ G INSPECTIONS
212 Main Street ' Municipal Builc6ng
2,,orthampton, Mass. 01060 ,
WORKER'S CONITENSAMN, INSURANCE A-FFMANI.T
---
�:'ith a principal place. of business/res�doncc t.
f�phone-=��
(si7C°tic It-Y", 'C:1!r)
r
do hel-cby ccy–Ll'1', tlI1CIti1 Llle p ISIS i.ii7 pC it ltle;; OI
( ) I am an employer providing tflc iollo�.v;nt '•�•<?rr_crs Comncnsauon covers c or my
employees wor-king on (Ills job:
(1=1r2-n= Company) C! Nu nbcr) ---- (rte pir.:ion Date)
{ j 1 a-m a sole proprietor, gene-,a± con—,�cyof home01:v71er (c:cle one) and gave nircd
the con—uacfors fisted (below `.i`hn t}lc' :`Olin _? ',:.'Ofke S C.07m. X0-1 0!i '.CS:
'NuaC of("or1L"aCtor) ( P.S nC LOli'n".;iF' Ol]Cf T1LliT1CCi) -Ut: DE!lC�
(Name of Contrc o:) (71ZS�r_nce Comp_::v/Pe!ie; Nuriltr_r) (1(i.ation Date)
(Name of Contractor) (In; slce C:; -;: }'iPolic: Nusillxr) (~.x.s:dos 1;ate)
- (Name of Contractor) — (TICE ancz ComT, WPOiiry Num'c.-r) Dare)-
(^!LlG1
/ " 1 ZU11 it :;olc prap[ICCJi ii:.'! ill:',c, ilo 0I1 ?" ; ill` for ii?e.
1 1?itl I? l:o?]lC 0�"vI1C� i?CrSC"I111I'a, al
NOTE iIcau t+ rtl's: . to
not:nece than tlircc un,? in t L di'd e f:: ;.i; r or oc;
c;:ploy`. ur rs
lcsal r-,ZLuf of an employer uadc t:rc wo<iu13 Coczr m alion AcL
i undc---xtwd the a an,y of thi. nuy bo foi.ti.,rdod to cfr[YtisrL c e of Indz ,riJ- M,-'ley 0'11c of for Ltx
oovr;agc va-MCtioa and that Eilurc to ur ?5 rl c(?.iGt,152 can Imd to ttx i.^politio'l
Co�=istina ota fine of up to s l of up to cr.:}' er.1 c ,it p=ultia in dr fc n of+Sic,,,
f rw
of's 100.00 a dsy lr�-ina m_.
F(,('dCS:ut3Z1'Z C31 li t�filly
S!r;nature cif;acc� Jf'crn „tr.: ,: ,
i
SECTION B-:CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
19'Reg�s ere "om ' m'br'o�ementContracCo , Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECT10N 10;WORKERS' COMPENSATION INSURANCE"AFFIDAVIT(M.G".L..cc 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"homeoNvner"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 St e of Massachusetts General Laws Annotated.
Homeowner Signature
��. _
SECTION 5,Dt=SCR P�ON^�OF PROPOSED y110RK[check Fa aDz Ip icable)
New House ❑ Addition ❑ Replacemgnt Windows Alterations) ❑ Roofing ❑
Or Doors
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: / S
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll ❑ • Sheet n
6al:f _f�ew "'""ou aitlor a:ifdt�onto:existingFi'ousingcompfeehe following
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
SECT10f�1Z,a ,OyI1NERAUTHORIZATION -:TO BE COMPLETED :WHEN
OWNEkS AGENT OR CONTRACTOR APPLIES, FOR BUILDING PERMIT
I' as Owner of the subject property
hereby authorize to ac,. on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of 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.
Print e
Signature of Ow; /Agent Date
i
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
i olumn to be fitted in b
This Y
Building Department
Lot Size
I
Frontage
Setbacks Front
Side L: R: L: R:
Rear
I
Building Height
i
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
I
parking)
i
#of Parking Spaces
-T
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT 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 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:
City of Northampton £� Y
Building Department
212 Main Street
Room 100
Northampton, MA 01060 ° C � x
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
ThES section tope '-d'b office
1.1 Pro nert�Address:
sa n
x k
0
Z&1144 1261,
�. 0 'Zoee ' .Overlay Drstnct
U
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED.AGENT
2.1 Qwner of Record:
le � c
Name Pri t) Current Mailing Add ss:
Telephones p
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3--ESTIMATED EONSTRUCTION,COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ' (a) Building Permit Fee
G
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)-1 Check Number
This Section For Official Use,Onl
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
909 RYAN RD BP-2004-1166
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 35-063 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category_ BUILDING PERMIT
Permit# BP-2004-1166
Project# JS-2004-1762
Est.Cost: $2000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 17206.20 Owner: MAKOFSKY PHILIP E&REBECCA J
Zoning: SR Applicant. MAKOFSKY PHILIP E & REBECCA I
AT. 909 RYAN RD
Applicant Address: Phone: Insurance:
909 RYAN RD () 586-1403 (�
FLORENCEMA01062 ISSUED ON.5121104 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL REPLACEMENT WINDOWS/DOORS
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 5/21/04 0:00:00 2054 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo