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j d DEPARTMENT OF BUILDING INSPECTiol.'S
212 Main Street ATunicipal Building
Northampton, Mass_ 01060
-. V11ORICERIS l..Ol'T-Ll .L'.if-\SAJ. ON IJ S lt!-1-NCE :11'1.1) A\'.j A`..
\ ILL z principal place of businessfresidence at: — -
(sum t/c�t J/sZ a tda p)
do hereby certify, under clic.p?.ins :md pen2lties of perjury, hai
( ) I am an employer providing the following 1%vorkcr's comocaSat;on covem—C for my
employees worlong on tills job:
GT
(LLr--D=Conram') (police: Nutnlycr) -- (a$11—Icon D2=) '
I -
( ) i ^ n a sole proGr'ictor, general coaLra Lor Or hoa-ieo' er (cZ(::e o!?t) 2nd icve hired
the conn-a fors listed below who hive the follollvinP- WOFker's c0m7ep_sa don pakies:
j (i`{smc o Cont naorl (InR+ranG: Cotnoan)vi'aGe; (Exuiracen Nate)
(Name of Contrzczor) (Insdranee ComDan•r/PoUmc `um cr) (Eapiraon Daft)
(Name of Coamclo.-) Gnsura.nc-- Company/PoUcy Nambu) (Expiraen Daic)
j
I
i
(Name of Connaciar) (Iasuran ComcaaylPolicy Numb r) (Espirdoa Dale).
(a'1.aGi1 or.=1 tk�,tf acoe�_-}-to a-icltt�iafoclu+�oa pete-iaiag to.11 ecc=--.=OZ) _- - -
i
O I .am a sode proprietor and have no ooe world-ng for me.
am..a home owner performing al! the work myself.
I NOTE:plea be ew ue ttii v Ie hemco aam wtio employ pczoat to do ca¢ �s,.:c.wo c rc,as••uric oa a d,.en_�of
not taocz th_a t.4o tmr�is tc�oy cbc bomorrwts-raido a oo the p oun6 appurtea_�the r•.n r c ox�rXy arc d-cd to be
eitployca ttnd the=k=-,nom.-_- ra Act(GL1t 52=1(3)).=pptin.000 by a bomooava fcr a lie. or panic r=y e idm«the
Iersl c+.•.-of ea—=PI—Y,wader dac Waned,Go�o Act
I
jI uadczz�ad tha a oopy of tbi.ml=—=oaay b.fore urdad to the office of L.—,am for d.
ca--- rcif erica
-ad th1 Liltat to seauc toverybz to d-seaion 23 A of MOL 132 c.Icd to the i-rwsilioa of a-imiaA PC-16=
eom.i:,i�of a f=orup to S 1 X00-00 xrWor 6=pr o orup to ooe yc= god c%17 pavltia in the focm of.Stop Work Ord-nad a
G=of S 100.00 a dsy apt me
For aep.ft -,t u-Only
f
/ Pcrmit Numb=
i.{an9-- Lot K
Stgnatur,c of Lic=Ls=/Pcrrr-Lj Lcc e l ¢
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DEPARTMENT OF BUILDI7�G INSPECTIONS
INSPECTOR 212 Main Street 0 Muuic:iptl 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 sup(::-:Isor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be,a one"or two
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 15TU Ong 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 iegulations. 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 buildin.2 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
r
SECTION 8-CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
l✓E; e n /'t I' ve �i� /7���Z��. i /z_s���
Address Expiration Date
Signature Telephone
S:Re isteretl Hume:tm'Rave`menttGoirtracto Not Applicable ❑
Company Name Registration Nm e6� -
Address _,� Expiration Date
3' w i�0 e e /-t Telephone
Coles/ o G
SECTION 10-WORKERS'COMPENSATION`INSURANCE AFFIDAVIT(M-G.L.c.452,§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-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 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
r
SECTION 5 DESCRIPTION OF PROPOSED WORK(check aflapplicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks Siding[O] Other[O]
Brief Description of Proposed
Work: /VG Sr�c � k,z-rte G� �Gt3
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa_tf 1�1'
ew•tiouse°arr�=br�ddt l io-6If vuslnsl0comratptP;:tW� inq:
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-Tor,BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUlLDINGPERMIT
`��� /Y� ��, ,-✓ as Owner of the subject
property
hereby authorize - /E'
to act on my f, in all matters relative_Ukwork authorized by this building permit application.
ignatu nee 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.
Print Name
Signature f wner/Agent D e
--
Section 4. ZONING Al I Informatibri 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 %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volurne,&Location)
'
A. Has a Special ever been issued for/on the site?
NO 0 DON KNOW 0 YES 0 ^
'
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON7 KNOW 0 YES
IF YES: enter Book Pag and/or Document#
�� ��
B. Does the site contain ubrook, body oy water orwmd ��wetlands? NO �~� DONTKNOVV x_� YES �~�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
'
Needs tobeobtained v�\ Obta�oe� �~\ Date
v�� x�� . .
C. Dn any signs exist nn the pruport �� ��y? YES �,� NO x��
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 grading, ur filling)over 1 acre oris it part ofo common plan
that will disturb over 1acre? YESK��) NO K )
� `�,
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
RA
y of Nort�ampton
u Iding Department _ e
2V Main Main Street �t♦v t r s
Y 1 1 2005 F oom 100 11 a ask e w a iti ��
No m �
ha ton;��MA01060 Setso �c�ia��Pas ,�, r
�1 p h qne 41- t�87-1 40 Fax 413-587-1272
APP T ATION TO CONSTRUCT,ALTER,REPA ,RENOVATE O DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1.-SITE INFORMATION
1.1 Property Address:
Thrsrsectionto be complet6 byoffice
l�E� Malr Lot Urtrt
�A Zone Qvertay DrstrrctY
�Elin Sti Distract =C6 Drsirict <;
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
/�{G.���I� �ti% ^':✓U,` �f Uc%�.��t'�/C 7�,E'i u�– I-z�lt�-i-u�c
Name ) Current Mailing>Address:
5 v �> 3 Ild;>
Telephone
ignatur
2.2 Authorized Agent:
/7/ ='/ '�i S/C/
Name(Print) Current Mailing Address: {�
-X13 3,- X13 -2 Y7 'V y
Signatur Telephone
SECTIO I Wa)ESTIM!AtED` ONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building �I�GC� (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) C) Check Number
This Sectiori-For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/inspector of Buildings Date
File#BP-2006-0163
APPLICANT/CONTACT PERSON John Zieminski
ADDRESS/PHONE 8 WOODRIDGE CIRC HATFIELD (413)247-9014
PROPERTY LOCATION 4 OVERLOOK DR
MAP 36 PARCEL 116 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildina Permit Filled out
Fee Paid
Typeof Construction: RENOVATE BATH
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/Statement or License 017889
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INF 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 Co ssion
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.
4 OVERLOOK DR BP-2006-0163
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 116 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Categor BUILDING PERMIT
Permit# BP-2006-0163
Project# JS-2006-0252
Est.Cost: $9400.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: John Zieminski 017889
Lot Size(sq.ft.): 16596.36 Owner: CONNOR RICHARD E&KATHLEEN M
Zoning URA Applicant: John Zieminski
AT. 4 OVERLOOK DR
Applicant Address: Phone: Insurance:
8 WOODRIDGE CIRC (413) 247-9014 Workers
Compensation
HATFIELDMA01038 ISSUED ON:8117105 0:00:00
TO PERFORM THE FOLLOWING WORK:RENOVATE BATH
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 Sienature:
FeeType: Date Paid: Amount:
Building 8/17/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
4 OVERLOOK DR BP-2006-0163
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 116 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0163
Proiect# JS-2006-0252
Est. Cost: $9400.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Grou*?: John Zieminski 017889
Lot Size(sq ft.): 16596.36 Owner: CONNOR RICHARD E&KATHLEEN M
ZoninQ: URA Applicant: John Zieminski
fir. `t
Applicant Address: Phone: Insurance:
8 WOODRIDGE CIRC (413) 247-9014 Workers
Compensation
HATFIELDMA01038 ISSUED ON:8117105 0:00:00
TO PERFORM THE FOLLOWING WORD.RENOVATE BATH
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: JI`,/! � Final:
3 Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: n;l. insulation:
Final: Smoke: Final: 3/. 05
THIS PERMIT MAY BE REVOKED BY THE CITY OF NOR'€HAMPTON UPON VIOLATION OF
ANY OF ITS !.!Ui,ES AND REGULATIONS.
Certificate of Occupancy Si nature:
FeeTyue:_ Date Paid: Amount:
Building 8/17/05 0:00:00 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo