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DEPARTMENT OF BUILDDJG INSPECTIONS
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 i:is/her construction sups.,• 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 fume y
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 boil mg department for t11-6 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 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 buildinz 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
L 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 tome
Date
Address of work
location
1
0 0 =_
ti 0-
LTf Torilli311lptoil
DEPARTMENT OP BUILI)r,\,G INSPECrf(D1.'S -
212 Alain Strcct - Municipal Building
?Northampton, Mass. OIOGO
1
WORIC—RIS CoNfPENSATION C SURA-NCE AFM,,' A, '
j 01 ccnscx-Jpermj rtcc)
%%IlLh a principal place of businesslresidence at: -
p.a. r� 7I x N. 14 A7ref(4) tit O2 O 1 Q (phone") �-`�
(sar...c/ci rJ/szatclD p) �'^
do hereby certify, under LI)c.p?int and penalties ofperjwy, Iial
{ ( ) I am an employer providing Idle follo%vine!workcr's coinocnsaoon coverage nor Ins
emplovees xvor'-,6ng on this job:
•
(Lcsur--n=Comma.•) (Polio:?pus r) :pirdor. DzLc)
;
( ) I am a sole proprietor, general contractor or homeowner (ci c:e one) and Dave hired
j the cooa-actors listed below wbo hive the `ollorvin2 worker's comnep_taaon pokles:
i
i
;
(N+amc of Con t^cior) (IRR mlic; cornown)-pi Dale)
I - -
(Name of COD G.mor) (Instuanez C,omoa w7olim, Daic) -
(Name of Coniz-aeio,-) (LasuraQc: C.om tPoG Names) (Expirarios Date)
I
(Name of Conaaczor) Gnsuran� CompanytPoticy Numb:r) (Expifaiioa Date).
(aC.aL1 ,. ..ocil t'ic�,irncccxa_�-to ctdu mfor=-:ioc perw;n; to all cow-_=.on)
{ 1 am-a sale proprietor and bane no one working for me.
( ) I aQ1:a home owner performing all the work myself.
NOTE:pl=.=be c-rt wt,o employ p,,=to d, ••,r c-,=,Oa c trau,+-ct'k on a d,,,-U of
ont meco th-a ` -its is-�ch the bomomwc rondo oc oa tic Qova,:!a z7purtca_=t.be-eo L-c w(C r Uy oec&---Od to be
citploycs ttnCc the w C==;>,- im Act(GL11 S2 a 1(5)�_,pliaboo by a bomcow=f=c lip--or permit r=r cNi�tic
Ie-p-1 c=uz of ea e=ployec under tbo wock�e,coavemilio¢Act
!uodezz..ad tin a copy of thi,mt®act my be fo-ard. to the I3eq.rtmea orIodrx- d Acodot7'M-of l-roc
cobc"eitCIioa and t1Lt t iltac to saatc:bovccaSe ta�dc sx3ion 23 A of htoL 152 m lc_d to tic izrxaitioa of cimina!pcaaltia
ooa==B of a riac to S I}00-00 a &C)c of up b ooc)s=r trod Civil P=A r=is tk roan of a Stop Wort ordc and
rim of S 100- a�y r,! me
Lot
Sim of tcu^JPcrmittr_ CE' I
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SECTION 8-CONSTRUCTION SERVICES 71
8.1 Licensed Construction Supervisor: ^^ Not Applicable ❑
Name of License Holder: Z) O y 1,0 )"y- C/_L U Q -I q ao
License Number
N z F VC t 1'J p,,4 4 s e T 4.
Address Expiratoi Date
7—
Signatu Telephone
9 Re`°'isereEtome'ln "ice�ieientoteaefar � x Not Applicable ❑
D � r v 4
Company Name Registration Num er
F.16 Cs 0
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVITT(WG:L.`c.152,Sa25C(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 Shan 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 State of Massachusetts General Laws Annotated. -
Homeowner Signature
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House E] Addition [�; Replacement Windows Alteration(s) Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding[O] Other(Oj
Brief Description of Proposed
Work: F I ML P ;:-T ID AJ //3 F x t:S�ifsti a s(2-Af '.A/7_
Alteration of existing bedroom Yes vNo Adding new bedroom Yes L-_No .
Attached Narrative Renovating unfinished basement t---Yes No
Plans Attached Roll -Sheet
r � � .� '�'}"�. F..�.8„`..�.e*" "e�rz5 � .,.wx- .. x:"� �., ,:.x�{v+��,,,; e .fi",^c;
ft �i l�ew IOU �t r ddif at c str c -horislnc::.comp etet[ a ti>f inn:
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
SECT[ON Ta-OWNER AUTHORIZATION-TO"BE COMPLETED WHEM_
OWNERS AGENT OR"CONTRACTORAPPLIES Fbk'BUICDING.I?ERMIT
as Owner of the subject
property V
hereby authorize �"' U .9\
to act on my be alf,in all ma relativ k authorized by this building permit application.
bra fZ
Signature of O ner Date
U A C 4 V L to as OwnedA rth�ori__;�_d _
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.
I fa-, 4 p ffvCa
Print Name
a a 's—
Sign ner/ gent Date
'
. .
'
�
Section 4. ZONING All Informatibb 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
Bldg.Square Footage % i
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume-&Location)
'
A. Has io| Porm�/Vuhance/Findi ever been bsuedfor/on the s�o?
'
NO DON x�� Y[5 x�v��� ^
��/ 7 KNOW �~� '
IF YES, date issued:!
IF YES: Was the permit recorded ot the Registry ufDeeds?
��
NO �� DONTKNOVV 0 YES
IF YES: enter Book Pageand/or Document
'
�� ��
B. Does the dtecontain abrook, body of water orwetlands? NO «�� DON7KNOVV �_� YES �~�
IF YES, has permit been or need to be obtained from the Conservation Commission?
'
Needs tobmobtoined x~~\ �btm�mad «�� Date
«�� x�� ' �
C. Do any signs exist on the property? YES K } NO �p)
IF YES, describe size, type and location:
D. Are there 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, .or filling)over 1 acre uris it part ofa common plan
that will disturb over 1acre? YEG � ] NO
~~� /
}F YES,then o Northampton Storm Water Management Permit from the DPW is required.
City of NortfPfampton e A
;l• ", '� Building Departmentf> ci#i7e
212 Main Street Se er ai tai x
t
Room 100
orthampton; MA 01060 � 5 oS drat
- � phone 4 3-587-1240 Fax 413-587-1272 Pro eans �
� _.A Qfhe�S�eetfj� „�4Tt.�ti�. •A�`` �� �n� , � �' .k
E �
cP I,4c0iO TO C RUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This sectron to be completed*Fz}foffice - "
1.1 Property Address:
Sit L 1 � Mai Lot Unit
Ve"� o�
k�$
r— [ ore A-ez , �
o i Q 6� - tone OverfaY:Distnct
Etm Sf District CDistrick_��'
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Curre ailin ddress:
• ( , 61
lr
TelepPbne
Signature
2.2 Authorized Agent:
0 ,/4A-f ri�MVP OJ0bb
Name(Pri Current Mailing Address:
Signature Telephone
SECTION 3--ESTI TED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
f C1 J
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC) c)
5. Fire Protection °�y
6. Total=(1 +2+3+4+5) P OO Check Number
This'Section'For Official Use Only
Building PermitNumber. Issued:
Signature:
i
Building Commissioner/Inspector of Buildings Date
File#BP-2006-0403
APPLICANT/CONTACT PERSON David Vachula
ADDRESS/PHONE P O Box 112 N HATFIELD (413)247-9459
PROPERTY LOCATION 29 SYLVAN LN
MAP 35 PARCEL 287 001 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:_PARTIAL FINI H BASEMENT
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 049846
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)
ir
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 Co sion
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.
29 SYLVAN LN BP-2006-0403
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35-287 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2006-0403
Project# JS-2006-0585
Est. Cost: $19600.00
Fee: $55.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: David Vachula 049846
Lot Size(sq. ft.): 66124.08 Owner: ABELL KIM BRUCE
Zoning: SR Applicant: David Vachula
AT: 29 SYLVAN LN
Applicant Address: Phone: Insurance:
P O Box 112 (413) 247-9459
N HATFIELDMA01066-0112 ISSUED ON:1011412005 0:00:00
TO PERFORM THE FOLLOWING WORK.-PARTIAL FINISH BASEMENT
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 10/14/2005 0:00:00 $55.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo