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36-105 (5) 4StfMlp�, O O Crzty of Nart4anyton z r � �'dassxclt�csctfs , DEPARTMENT OF BUILDING INSPECTIONS INSPECTOR 212 Main Street • Municipal Building ' Northur►pton, MA 01060 HOME OWNER EXEMPTION ACKNOWLEDGEMENT The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to act as 1 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 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 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 until such time as the proper permits and inspections are made I, understand the above. (Home owner/resident's 'g ature requesting exemption) I will call to schedule all requ'ir building inspections necessary for the building permit issued to me. Date_ _ z Address of or location � � 0 0 LX Rfi ti Crii� �f porfljarlipfail - iA .61csaerllasr116 DEPARTMEIJT OP IIUILDr1\C INSPECTIOI.'S - 212 Alain Strcct Municipal Duild;nC Northampton, Mass. 01060 j VY'ORJC ZITS CONMENSATION INSTJRA-N(-F AI=AVj-j- (li mmS--cJperrrl;ace) a principal place of business/residencc at: _ (phone') (Succ- 6ty/suir-lzj p) do hereby ce under d)c.p?snand Penalties of pc - =.hai I ( ) I am an employer providing the following workcr's comocnsado, cove lie for In) etuplovees worbog on Lhis job: (Iamran= Comr._a)•) (Polic. I;LLmncr) -- (r;-pintion Du.e_-) ( } I am a sole proprietor, general contractor or homeourmer (c c;e orle) and have hired the contractors listed below who hive the foUo%vine worker's coLaenSa6on policies: - 0"laiD Oi COnt^ci0r) Col paI)./!ouC-i ?�`UII1�C:) �_':71F1L•^ t�llC) i (Name of Coocncior) ans-aranc;- C.omoanyrPolimi Nu06^-.0 (-ExPL7.6on Date) (Name of Conl7aao:) (Lnsurancc C.ompan)-fPoliq- Namber) (ExpLmlJon Datc) (Name of CAntnctor) (Insurance Comcatry.(PoUcy Nllmbcr) (Expiration Date)- (siYst�_di1;;'cr31 t5c�,iraccc--a.ry t.o aic?utL iarorm,soa pctta'�w.11 oca�-_.c.o:�) - { ) I am a sole proprietor and have no one working for me. �j I am.a home owner performing a1i the Nvork inyseif. `NOTE:plec lx e a in tti,j k{�jet6eme�o�ve�n wbo cxaptay p="Zrm w ei� • . _, c=,,=—m c rcp*-v..•orx on.d en:y of ant LLOft 1�'.7(,�Sp:Llfi7 ul lt�cb[bc bom00% r=&=oC oa tb4�zy6. z.��y���� Ll�p LT DCK .t1Y OCQ:dcrcd to tK l0 tlarc the k 'r "i l'Y�____ C"`)C"'. ATP YCZ x5 d:c=2pc c.Act(GLI52-al(5)) :ppliradoo try a bomcou-=fm a bc�--or pama,ray eyed' tEe I'PI n.aau of ea a Ployo under tbo Woric.oda GoozpomaLioa Act_ f uadalayad tha a Dopy of Lbiu aatcm may be r--,td to tbo D.;,••••..-•..•of lnd.cxricl Am&.t'Offi—or 1.--n for L6. oovca.sc vcrifc=loo and ttu L• =i t to LCOJ=Pave Linda uxMon 23A of 1.foL 152 tan Icd to the i2Pcaition of criminal pcvaltic coa==z ofa fiat or up to SISoo.00 srtd/or ofup b one yc=r LOG civil pm ttia n t,roomofd Stop Wort;Ordcr rind a riaa or S I Oo.00 t d_y tpinst me For permlt Numtxr ✓__4 'z�G" - ___ U �t 1,Lapp—_ Lot � S i mature cif Lia=isctJPc rmi ucc e J SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder: License Number Address Expiration Date Signature Telephone 9: e stereci:#�omem navement'?Gontractar =' - -, ,; .��` ,,; x� Not Applicable .❑ Company Name . Registration Number Address Expiration Date Telephone SECTION 10-WORKERS"COMPENSATION INSURANCE.AFFIDAVIT(M.G.L.c.1-52,§2SC(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 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 9 Y SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors O Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [O Siding[0] Other[0] /Brief 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 s �'�;�zE .,.- "`.' " "b.:'R` 's."iar r b '"'' .'#LS'_ :to-x � .: *,rw�w. sa 1f te�nrtseodor .cic�it�ar ©,e�nsinci t>o>asrna:c�om ►" ems ;1'iowl�zg; 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 L 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:AGENT OR"CONtACTOR APPLIES F.OR=SU[LDING'P.ERMIT 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. Prin,kName Signature of Owner/Agent (Date f r - ` ' Section 4. ZONING All Information 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 % 7---7 (Lot area minus bldg&paved 777 #of Parking Spaces (volume&Location) A. Has a Special Perm it/Varia nce/Fi nd i ever been issued for/on the site? �� �� NO �_��� DON7 VV �_�KNOW YES «_� IF YES, date issued: IF YES: Was the permit recorded at the Registry ofDeeds? ' �� VV NO �� DONTKNO YES IF YES: enter Book Page and/or Document#| , 10� v~� YES �~� B. Does the site contain u brook, body ofm/atarorwetlands? NO �~� DO@7KNOVV �~� �_� IF YES, has permit been or need to be obtained from the Conservation Commission? Needs tmbeobtuined �-x Obtained x~� Date «�� �~� ' . C. Dn any signs exist on the prupert ��y? 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 0 NO 0 IF YES, describe size, type and location: E. Will the construction activity disturb(clearing,gradingexcavation,ur filling)over 1 acre orioitpart ofo common plan that will disturb over 1acre? YEG ���� NO � � �� IF YES,then a Northampton Storm Water Management Permit from the DPW is required. ^ _ w City of Northampton J4 Building Department 212 Main Street ` Room 100 ri�i7 1 Northampton, MA 01060 . p �- 72 f�r s one -587-1240 Fax 413-58 12 APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -'.SITE INFORMATION 1 Property Address: Thrs section to be completed b, affice Overlay Drstnct ,EIm�SL�'listucf=:' ' �. •: „_°, �CB�D�stnct` _ SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT —T 2.1 Owner of Record: Name(Print) Current Mailing Address: Telephone Signature 2.2 Authorized Agent: Name(Print) Current Mailing Address: .r- Signature �— P Tele hone SECTION 3 ESTIMATED CONSTRUCTION COSTS- l em Estimated Cost(Dollars)to be Official Use Only completed by ermit applicant 1. Building r \ (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 Sectlon For Officlal Use Only ,Building Permit Number. .Issued: Signature: Building Commissioner/inspector ofBuildings Date BP-2007-0191 GIS#: COMMONWEALTH OF MASSACHUSETTS � ,.1 ., CITY OF NORTHAMPTON Lot: -001 Permit: Building Category BUILDING PERMIT Permit# BP-2007-0191 Project# JS-2007-000290 Est. Cost: $1547.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: Homeowner as Contractor Lot Size(sq. ft.): 16944.84 Owner: DZIUBA WILLIAM M&BARBARA A Zoning Applicant: DZIUBA WILLIAM M & BARBARA A AT: 931 BURTS PIT RD Applicant Address: Phone: Insurance: 931 BURTS PIT RD (413) 586-1226 (� FLORENCEMA01062 ISSUED ON:811812006 0:00:00 TO PERFORM THE FOLLOWING WORK:REPLACE PICTURE W/BOW WINODW 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 8/18/2006 0:00:00 $25.003137 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo