35-146 TtlAMp), c -
$ � �i'rlassac3tasefts
t DEPARTMENT OF BUILDDtG INSPECTIONS /
INSPECTOR 2'12 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 has/her construction sups: , ssor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or tW6 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 ofNorthampton 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 fegulations. 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
equired can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home owner/resid n ' sibnature requesting exemption)
I will call to schedule al required building inspections necessary for the building permit
issued-to me
Date /
Address of work
location
O¢Ylt/J-tP�0 f .
f � yam---=
(riff Of '.�orf11a1)l�toll `
8 � �' ��caakr}lasrlle- _
o DEPA i ME1 T OF BUILDDI\10 INSPECT IOl S -
212 Main Strcct Municipal Duilding
hrorthampton, Mass. O1OGO
i
WORICC IS CONITENSATTON' »S CE 1.l
piccnsxlpc;m�ctcc)
wILb a principal place of businessfresidence at: -
I
(phone-!)
I
(sa /drJls1=1zip)
do hereby cerify, under Ll)c pains and penal Lies of perjury, ha l
i ( ) I an an employer providing the followin-,!,,:-orkCr 5 cotnocas_n:io, Coverage for III)'
elnplovecs worlong on this job:
(inSUr�c Conr._r.,`) (Police: K-u_-nor) -- (-xpiraor. DzL.)
( ) I am a sole proprietor, general conu-aaor or homeowner(ci c:e onc) and hzve hired
the cona-a(nors listed below who have the follov.,inQ worker's co�oen_�oon pc!ties:
(1+^SIJC Oi C0:I.!^CiOr) (Irisumncr_ cornownylpouci !"IU1II=rI) �t`;J1.dL•�?? ��.11C}
1
I -
(N mzc of Conczctor) (Uis"xanec Compan}•lPoUe Nunc=r) (Ex—mm;on Date)
(Name of Conizaclo,) (Lasurancc Compan y/Polk}- Numbzl) (,_xpir=aon Daic)
I -
(2`2t c of Cnnlxartor) (Lnsuran Comp
azy/PoLicy NuQbzzj) tpirauon Dart).
(.Mach:ddii'ocil e—ifacc.._-,to c,cuc=iafora.:ioc P=-L�to.11 cat -s s Q=)
{ ) I am 'a sole proprietor and have no one worL-i-og for me-
I am..a home owner performing all the work myself.
NOTE:pi=.=be conic tfi,. .Jc bcmco..ac^s.,,-bc caplcy p,=-O=ie do t.+si ,c=,=Joo c rtpair w aric w.d..c -;of
CDC ancr th:a 'u_a_timr's is ujmeb the bomoowvc r=d=or oa tde p-ouacS zrteo�=tbcc-n t,ox C-_r=Dy ocp.d_-cd w be
j -avicy_z u the zcS c c •P-�m Act(GUI 52-=1(5)},_pplim6on by a bomoaa=-fc_6=c- oc Pe h ciy nid�t>~
legal ct=s<of a <.gloyer under d.o W ortcla co¢�a I,d
I
I—4---d thQ n copy of tb-6 may be foci ,d-d cn the ocp� rl.&,,-,;.l Aeaa..&oiL—or Inav+oea for th.
cove'- vc6c=im snd the Liltac to&ca=tovcre.sc und'.'sociioa 23A of MOL 132 c=I=d to the=Posi ioa of critaiasi Pend'
00—iZZIMS of a 6=or up to s 1 S00.OQ.s0or 6=pr of up to yr=r cad i.�1 pcwlie in the roan of.S�oP Wort Ordc aad a
fl=0(S I OODO a d_y cVI=tzx
. Or a�az cur+--Y K C1I7
' !,( �CrDj t Niln LJ
l ��Vww"�L_
Lot R __
Sim Wrt of Lic=ISc&4>C rrrLi bite
SECTION'8-CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
`� NotApplicable ❑
9:'ReatsfeTe" one Inprovement inira�ctor� , PP
Company Name Registration Num eum ems—-—"—
Address Expiration Date
Telephone
SECTION 10-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...... ❑
on
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-vear 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 hirc to perform work for you under this permit
The undersigned"homeowner"certifies and assumes responsibility for compliance with the State Building Code,City of
orthampton Ordinances,State and Local Zoning Laws and State of Massachusetts General Laws Annotated.
_
Homeowner Signature
r
t
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [] Addition ❑ Replacement Windows Alteration(s) Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [❑ Siding[C7] Other[p]
rief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sax IfNevi��ouse= nT� �difon tsx�extstin4:you°s>ng:.�ompte'tethe��otiQrn�irla:
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 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENTOWCON RACTOR-
TAP,PLlES.FOR BUILDING-PERMIT
I as Owner of the subject
property
hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
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.
uJ ,
Print Name -
Signature of Owner/ gent Date
, ..
�.�
Section 4. ZONING All Informati6h 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
Rear
Building Height
Open Space Footage %
(Lot area minus bldg&paved 7-
#of Parking Spaces
(volume,&Location)
A. Ha's | Perm it/Vohonce/Findi ' anerbeen issued for/on thesite?
NO 0 DON7KNOV 0 YES 0
'
IF YES, date issued:
IF YES: Was the permit recorded mt the Registry ufDeeds?
��
NO �� uum / ^muvv 0 ,cx
IF YES: enter Book Page: and/or Document#/ !
B. Does the site contain a brook, body uf water urwetlands? NO �~� DONTKNOVV �_� YES
IF YES, has permit been ur need to be obtained from the Conservation Commission?
-
Needs to be obtained x°~\ Obtained ��' Oate|ssued�.
x_� �~� '
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: it
D. Arethere any proposed changes to or additions of signs intended for the property? YES 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,cn filling)over 1 acre cvis it part ofo common plan
thowW|distu,bovor1onm? YES � } NO
� �
`~� f ~~�
|F YES,then a Northampton Storm Water Management Permit from the DPW is required.
- r-�" �� ,De per► ause�onl�,�� ,�. �� K , .
Northampton
r
In'
Departmen �
^, �c Main Street a � �� _
om 100 v
'ONor ` ton; MA 01060 #per
phone 413- 87-1 40 Fax 413-587-1272 ata 3
n n ^
-ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
APPU eAtON-fD-C6RS ,
SECTION 1 -SITE,INFORMATION
This section to be completed byoffice
1.1 Prooertv Address:
-73'v Ry�-
Maps � •Lot �- � Unit
��� �' I '( Zone OverlayDistrtcf
a� x ,
SECTION 2-PROPERTY OWN ERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
CV- 4E-"k')
Nan'te(Print) Current Mailing Address:
Telephone
y
Signature
2.2 Authorized Agent:
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 (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
This Section Fdr Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
734 RYAN RD BP-2006-0186
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map-Block:35- 146 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0186
Project# IS-2006-0280
Est.Cost: $5000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 9321.84 Owner: LENKOWSKI TODD W&SUSAN E
Zoning; SR Applicant: LENKOWSKI TODD W &SUSAN E
AT. 734 RYAN RD
Applicant Address: Phone: Insurance:
734 RYAN RD
FLORENCEMA01062 ISSUED ON.8119105 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE ROOF
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 8/19/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo