36-174 i y
-
O
Gift' of Wart4amptan z
�I ASSAChIfSttts
DEPARTMENT OF BUILDING 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 his/her construction sup,-,:-.",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
requir can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
o e owner/resident's signature requesting exemption)
I will call to sche ule all required building inspections necessary for the building permit
issued to me.
Date
Address of world
location l U t�}r C2(^(r
_- r
� - 6 hlisia(Eltis(tts
m UE1'/-aT?iEA�r OF BUILDING INSPECTIONS
212 11Tnin Street ' Municipal Building
a
Northampton, Mass. 01060
WORICER'S MMTENSAUON INSURANCE AFFMA IT
til a principal place of bus, css/res dcnc
(phone- - -
t
CIO hereby Cer-dfy, unaef rile 1:.:ns gild pen;iti'es of perjury, t.ha_'_
I cII1 an eIIlplO}'Ci' prOVldln, tile "or Iny
caiployet's working un dils job:
(Insu2nG Cotsm') cc.i�rt�tbcr) (rx.T-imden Date)
j I al a sole proprietor, 2eneral con-�:=`or homec%tl r ( cle Oct) and 'tla,e hued
t.11`� cont 11S:ed be.0vr i'h0 i?�'.' tll? `O!I. Il 10rcCerS COu penSc On `011C: S:
r--
(Name of ConLmctor) TE5-1 rZIlGC 1G'�atC)
(Name of Conte etor) -- (711s�r,_r.c� Coy�arl�/Pe!ie Number; (E`:Lr.:Tin Date)
(Maine of Coat-acior) (Ins-urnncc ( o J 3]'i/I�QI:C. NUSIlt%r) - '.X rai]C hale)
- (Name of Contmctor) _ (Ins razlc� Color vly!Polier Nu.mbir) lI:;ri-aioc Dare)-
(.^.tLl Ll-r�-;ItI CY:iI S_.:mot:• - -' :n:�r1...:'-::::-Y::•.a::.K:r..—•- .. ..ii
1 <LIl 2. UlC i?1 Ul?S1CtUi Tait1 i1SV no 0 1:', 01 F,-.-iii` 10i Tile.
( ) ?iIl �? 110n1e C1'lI1C.' l)Cr.C�Illln; all itl ':'•_ ..- iii`tS t.
*:Q•I-F::plcsc be a:vzrc tl:�t•.���ilc lx<-„co.ar.::r,-o r.---1�'it;:-=���;t����'-'::zncc,a:.r_n:��m a:�I:,it,� ......_�:.cl!ir.;c.
not Here Ltt n thmo uuiU ir.�a{ �t he f:;z±;:tie r :c u o;J'` :.:i z of cr_r1 Lhcc o c c n t Ccx ( o h
c.-:ployc3 un,,- r t}r iwci:mss cc x-_:atirn Act(OL!52.:s:(5)),al:;Lc:.:ia: y s hotncon:�f for e par.^.:i::: rtie
lcgzl etatuc of an atployer udder thn WocYCra Com- -• 6a n!.cL
I wade-stxmd thi:a copy of 11v n: y to fo.--,rd J tot: Dcti t,,—j:of Lod triel Actzr-m!y Offlo of':='au..."'_o for the
aovrrige vcr-ifiertioa and the t failure to tcntre cnl.cr_F,ut d r eC.ic 25A of MG1,152 can Ic:d to the imposition ot”e 1 petsl::es
comizt, of a fil of up to s l.S -00 aad'x ir.:pr,.r ;1 of::p to rs.1 civil-,XM tia in tic toxin of a ste},`;Jeri_0-,'=erd
Lr OC I00.(?0 a city ts�"ina m:. .
_ (f!
For(Sa:uutnt�u.e ctlty
�, `��� Pcrrnit riumtr.;r ---
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ion. tore of i.Teen:cJI'crnr,;tr
SECTION 8=CONSTRUGT:ION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
[9 Reg s e e R time#mp MOM t Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION'10' WORKERS'COMPENSATION INS J" NCE AFFIDAVIT(M:G L.-.c. 152, § 25C(6))
, x ,
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...... ❑
9
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)fami:ies
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 "homeowl5evIrcertifies and assumes responsibility for compliance with the State Building Code,City of
Northampton Ordinances, at and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Xwrneowner Signature
SECTION DES F,j TIONOF#�FtOPOSED WORK checkta71 a licalle
Pn
New House ❑ Addition ❑ Replacement Windows Alteration(s) Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ) Siding[ ) Other [ ]
Brief Description of Proposed Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No /�
Attached Narrative 0 Renovating unfinished basement Yes — No
Plans Attached Roll 0 • Sheet 0
f�:.e. ou ; : n o a'udi't=ro �existin �housrn"�°co""°�n '�°Ie ,e�`he�fol-low ni
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?—K) V
d. Proposed Square footage of new construction. Dimensions
e. Number of stories?
f. Method of heating? Fireplaces o oodstoves r
e Numb 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 con/form to the Building and Zoning regulations? Yes No .
I. Septic Tank / City Sewer Private well City water Supply
SECTaQ�L DINER A[I1 ORIZATION Z70 BE COMPLETED !WHEN
OWN�Ef(SA�E ORCONTRACTOR'APPU'ES FOR BUILDING'PERNIIT „`
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' `Q)rJ as Owner/Authorized Agent i
hereby declare that the statemen and information on the foregoing application are true and accurate, to the best of my
knowledge and belief.
Signpo under the pains and penalties of perjury.
Print Na e
Te ner/ gent Da
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Side L: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW YES
IF YES: enter Book Page and/or Document #
B. Does the site contain a brook, body of water or wetlands? NO ✓ DON'T 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
tuilding Department
C
212 Main Street
Room 100
ort ampton, MA 01060
X13-5 7-1240 Fax 413.587-1272
1
Ptl
CATION TO CONSTRUCT, ALTER, REPd I E V E R E 0 VSH E OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION l
€4�' r1 ectro Ito"ticomPI`tebyoff ce
1.1 Property Address:
WOW
709' 6-ey-\C Q MaP ` Lof
MAIT
p --
,'
t ob � Zone �� 5 Qvxerlay D strict ���� �,
T— Elm 5t �ISt(ct GCB Des Ticf _ =.
SECTION 2 -'PROPERTY OWNERSHIP/AUTHORIZED-AGENT
2.1 Owner of Record:
&,: ,% " -)o'i Rorev--�c� t� tlalffv-
Nam rint) Current Mailing Address: 3 C , AA 1 0 ft2-Telephone
Sig e -
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone _.
SECT10 3 - ESTIMATED CONSTRUCTfON COSTS
Item Estimated Cost (Dollars) to be Official Use'Qnly
completed by ermit applicant
1. Building (a) Building Permit Fee
00 -00
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 dumber
This Section For Official Use Only
Building Permit Number: Date!Issued;
Signature:
Building,Commissionerllnspector of Buildings Date
7W Fu NCI✓RD, BP-2004-0351
GIS#: COMMONWEALTH OF MASSACHUSETTS
,MW;,Blgck:At;—174 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0351
Project# 35-2004-0507
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 14549.04 Owner: NYKORCHUK KARI M
Zoning: SR Applicant: NYKORCHUK KARI M
AT: 709 FLORENCE RD
Applicant Address: Phone: Insurance:
709 FLORENCE RD
FLORENCEMA01062 ISSUED ON:9129103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL PELLET STOVE
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: Receipt No: Date Paid: Check No: Amount:
Building 9/29/03 0:00:00 528 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
709 FLORENCE RD BP-2004-0351
CIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 174 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
category: BUILDING PERMIT
Permit# BP-2004-0351
Project# JS-2004-0507
Est. Cost: $3000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor., License:
Use Group: Homeowner as Contractor
Lot Size(sq,ft.): 14549.04 Owner: NYKORCHUK KARI M
Zoning: SR Applicant: NYKORCHUK KARI M
AT: 709 E0RFNCE RD_
Applicant Address: Phone: Insurance:
709 FLORENCE RD
FLORENCEMA01062 ISSUED ON.9129103 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL PELLET STOVE
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: Sr:clllP• ^:nal: OK 10-97-63
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLAT OF
ANY OF ITS RULES AND REGULATIONS. �,O
Certificate of Occu an Si nature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 9/29/03 0:00:00 528 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo