25A-112 i +
�1HSDACIfliStttB
Fify of Warthamptan )T-)
DEPARTMENT OF BUILDI]�G INSPECTIONS /
INSPECTOR '212 Main Street • Municipal Building '>o
North,unpton,MA 01060 5 `
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HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction supc:-,'s,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 famII
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
� - r
I, derstand the above.
(Home owne� esi exit' signature equesting exemption
I will call to sche' le all re fired building inspections necessary for the building permit
issued to me.
Date
9- °
Address of work
location 6 C% C� �y,,�,, At _
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of '.�nrflja�)t}�tDti
A J f �tasswcllrtsclla' _
DEPARTMENT OP BUILDr)-,'G INSPECTION'S
212 Main Strcet ' Tfuntcipal Building
Northampton, Mass. 01060
WO R.ICC R'S CO I TP ENSA'nO N LN S URAIr CE A F M,U)A VIT
I
i
�i (Ii ccvsxlpcTmi tics) .-- -•- —-%,.,i Lb a principal place of businessfresidence at:
(pl-1one�')
(scr�1/a ty/SlatG�Z7 p)
do hereby certify, under thc.pains and penalties of perJury, ---h2i
( ) I am an employer providing the folloxving!vvorkcr's comocnsarion covemgc for Illy
etul)lovices worI3ng on uiis job:
I
Conr, m,) (Polio:NunriDcr) — :piratior,D21,^.)
i
( ) I am a sole proprietor, general coca-amor or homeow-Der (ci tie o-!e) and have hired
the coauactors listed below who have the follollvi g workers comptnsa➢on pa!icieS,
j
I OMIM: Of Co_?t:-aor) (lnRranc Cotr101r1)-01 o6ci ?�`um=<:) (Yti l<J:ion gale)
(Name of Contractor) (L surznc= Comoanw?ob(n Nuncnr) Date)
(Name of CoairaCt07) (lasvrance Company/PoUcy Ntrsbcr) (Expimaoo Datc)
I -
(Name of Contractor) (Insumcc- Comparry/Poliey Numb-`r) (Et�irtio0 Date).
(as If :duzoc�!r'xd,irncc.--,to mood;�iaformvzioa p�-saiains to.11
( ) I am a sole pr-opnetor and have no one workdDg for me.
i ( } I am.a home owner performing all the work myself.
NOTE:pl==be aw=th <.•!v)e bca r=<von<vbo ctaploy peso=to cto rr cs e,00 r repair Woric cs c d-xIL^C of
one mote rhea U,S- tmri ma wSch the bomoo.acr reed=(x oa the pvu d,zppurtc==tbe-da z c auc C--�z-_lty occsid rui Io L-
aixployen ul)"—the---kc?,oc=P=:-z,.cc Act(GUI 52-=I(3)),=ppliaboa by a boa=%-=for c licx_cc pa-rah c=y cv-dm the
lc-ga.T n"^„of as e_Ployx coder dto Work et Coazpomatmoa AcL
I
. I unda�taad tb.d>Dopy oC lhu mtc a�m...y be foc�.vd.d to cbo pcputmmd of In�+tti<I Acddmt�'Offioe of Irta+�o�for tb-
ooven se vaif euioa and th-11 failtac w smue toverasc under soetioa 23 A of}toL 132 na la d to the iyposirioa of airmail peaalsic
comiring of a fine orup to S 1}OO.Oo andcor impri3,o a of up w ooe yor c_od coil pmaltia io tSc room ore Stop Work Ordr and a
(� rim 0(5100.00 a ay Lpiaa tnc
for only
PCrMjt I�hunt-- -
j -- Lot
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Sipoacum of Liom =/Pccmiucc -- ate
SECTIONS-:CONSTRUCTION SERVICES + '
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder
• License Number
Address Expiration Date
Signature Telephone
_.
9eais eye' om '�nA`�Q�eme M=°�tra�a Not Applicable ❑
Company Name Registration um er --
Address Expiration Date
Telephone
SECTION 10-WORKERS'CQMPENSATION INSU NCE AFFIDAVIT(M.G L c 152,:§25C(6)j:
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 th tate Building Code, ity of
Northampton Ordinances,S ate�nd Local Zoning Laws and State((of of Massachusetts�Gene Laws ted.
Homeowner Signature
r
SECTION 5-DESCRIPTION-0 PROP
New (check all.auplicable)'
New House ❑ Addition ❑:;: Replacement Windows Alterations) ❑ Roofing 0
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0) Decks [0 Siding Other[d]
Brief Description of Proposed
D n U U
Alteration of existing bedroom Yes o Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes _�No
Plans Attached Roll -Sheet
sa # v is rs+ n
lion, it cl:
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 BEGOM"PLETED WHEN
OWNERS AGENTOR CONTRACTOR APPt(ES`FOR BUILDINCx:PERNIIT
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.
Print Name
Signature of Owner/Agent Date
Sect' 4 ZONING All Informatioh 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 S' I I I
Frontage I
Setbacks Front i
�1
Side L:� � R:� L:� ` R:= �---�
Rear (�
Building Height
Bldg.Square Footage �" �� °/U ;
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
(volume,&Location)is I
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued:? }
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book i ( Page! I and/or Document#( G
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Obtained , Date Issued: j
C. Do any signs exist on the property? YES 0 NO 0
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:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 , NO
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Nortfa;ampton
Building Department
212 Main Street
Room 100
Northampton;MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION'
,, � This sectron to lie completed by ofFice
1.1 Property Address:
/ //-/(��
dotne r�, ; � r , Overlay Distract
iY% i2r{4'.ii
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
i C o e / fl. �d �h -� �/2 6 Z o L D �C'r-m A n �✓�. �c�T�am,6!O n
Name(Print) Current Mailing Address:
�]r n /� -I
tX G� elephone
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 Bung Permit.Fee
4. Mechanical(HVAC)
5.Fire Protection _
6. Total=(1 +2+3+4+5) to, Check Number
This Section For Official Use,Only
-... .. Date.
Building,Permit Number ,Issued:-
Signature:
i
Building Commissioner/Inspector of Buildings Date
now
60 SHERMAN AVE 13P-2005-0280
GIs#: COMMONWEALTH OF MASSACHUSETTS
MapBlock:25A- 112 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2005-0280
Project# ]S-2005-0364
Est.Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq.ft.): 8799.12 Owner: DROZDAL MICHAEL&PAULA
Zoning.URB Applicant: DROZDAL MICHAEL & PAULA
AT. 60 SHERMAN AVE
Applicant Address: Phone: Insurance:
60 SHERMAN AVE
NORTHAMPTON MAO 1060 ISSUED ON.918104 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSTALL SIDING
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: Receipt No: Date Paid: Check No: Amount:
Building 9/8/04 0:00:00 1396 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo