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vM DEPARTMENT OP BUILDr\10 INSPECTIONS
212 Main Strcet ' Municipal Building
Northampton, Mass- 010GO
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WOfUCER'S CONOENSATIO'N L'1SURA-NCE AFFMA.A71-I'
i
(li cc-nsxlpertnl flee)
%lath a principal place of businesslresidence zt: - -
— (phone')
(sII-t~.t1ci t`J/natc�ri p)
do hereby certify, under dic.pains :md penalties of pc'wy, .h?.l
( ) I am an employer providing the following!workcT-s corrlocnsador. covervge for Ins
elnployces wor-ong on this job:
i - (Insuxan=Complay) (Potic-. Number) -- (I':-pirrior. D2=) '
( ) I am a sole proprietor, general contractor or homeou aer(ci cie ore) and have hired
the coniTaclgrs listed below who hive the foilowiog worker's ca0Den_t26on pakies:
I
('f c of C0:=Cr0r) (Instrant: Comt)a,I)•i-1'oiie;
1
I
(Nzmc of Conc aor) (Ins,lran COmDai•1)v?0UC- Numb_r) (i»ir;on Date)
I -
(Name of Co=aCior) (Lasvrane Company/Policy Munbu) (Expir.:aon Dalc)
(Nzmc of Conaaaor) ansuran= Comcz.¢y/Policy Number) try iraaon Dar-).
vocal�ca.if M.0==_y w inch iafwxa�oa pciaiaias w.11 oocr�:a) -. _-.......
I
i -
O I am'a sole pFOpn'etor and Gave no Oct worlong for me.
J I am home owner performing all the work myself.
tn
I ! ��NOTE:pl==be tw-u=rl-�jzDc bemeaw-oerabo c=pioY Pew=eo do�-•:•.•,-•••••r cr..:.e�oo a rraaa•�-oric as a d..�r�:^�of
I aoe more lb--n ti'ao =rs is%%Jmcb Fbc bomoowvc roedo or oa the po�ia6 zppvrtca_rs tbeen�z we C=�=-Uy oee:d-ni to be
{ enploycs"mac the" -- '.�Act(GUl52-=1(5)1=pplinaoa by a bomma-oa rc a!ice-or permit o_y e.4&—the
Ic-I.I rc.-^,-of ea—Ploys "odor dh Woekce,Caa>P•om+.lioe Act_ '
I
� I - w�¢a Dopy of this ml.cmca o7.a be foa>.ard.ed to
Y the Dryertmoo¢of Iodustia!Accd�'OQ.oe of Grur•oae Car th.
Sv c mil csioa nad that Li]tac to saauc to
veysc=d=zOctioa 23 A of h(OL 152 as Ied to the i=qxisi ioo of crimiasl peril=
eaosi=iag of a fioc or up to S 1X00.00 m&or ca;n iyo=Dc=t oC"p W ooc ye-r sad civil pca+.Puo is 6c roan ora Ssop W orE Ord-aad a
fl=of S 100.00 t�y tFpia�me
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., For 'U'--jJ U-only
Permit Plumb r
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Lot
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P—Wrc of Lioms=fPcrrniucc C I lz
Og�H ATO
- �l ASSACjj3IStZfD
` DEPAaTMENT OF BUILDING INSPECTIONS /=
INSPECTOR '212 Main Street • Municipal Building 'a
Nortliaur►Pton, MA 01060
r
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as his/her construction super-. sor_ The stale defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two farm _
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 6uildi`ng department for t11e 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
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 ��Z5 S C 12 Yh A r\) >9 U
YVr
SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
3wRe°Tsfeced}Iome=liri ravemeolt Cdntracar m. Not Applicable 13
Company Name
Registration Num e --__.__
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION`INSURANCE AFFIDAVIT"(M.G:L.c.152,.§t25C(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...... ❑
AN:
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.AAperson 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
r
i
SECTION 5--DESCRIPTION OFPROPOSED.W.ORK(check all~applicabiel
New House ❑ Addition ❑: Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [p Siding Mta"" Other[tom]
ief Description of Proposed
Work:1, 1Iy N43 gig
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
-^ �+rsr - x1.°°; .—ea.At•.:s-.^'- *.i-:,- -a3 r,f:':." ._.,,.a•"°.".�":..�.. -a =, qz ., .Y?: mx^,- iN," w,w.°•
sa_ff'[�I�W=froras�an4or��ciEtio�ril t€�exst�n�[iou$iilcr cOrxip�tet��k� o[[c irQ�
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 AUTMORIZATION,-TO BE-COMPLETED. WHEN
OWNERS AGENT.OR C;ONT.RACTOR APPLIES FOR BUILDING.PERMIT
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.
rnI x L
P'nt Name
—J
Signature of Owner/ gent Date
*
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Section 4. ZONING Al I Informatibn 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 %
dg&paved
(Lot area minus bl
#of Parking Spaces
(volume,&Location)
'
A. Has a| Pennit/Varance/Findi ever been issued for/on the site?
' x�� x~� '
NO �x~�~� DON7KNOVV x°� YES �~� '
IF YES, date issue& |
IF YES: Was the permit recorded at the Registry of Deeds?
NO �_��
� uum / ^muvv 0 ,ES
IF YES: enter Book
Page, and/or Dooument#
B. Does the site contain u brook, body of water orwetlands? NO 0 DONTK0OV 0 YES 0
IF YES, has permit been nr need mo ba obtained from the Conservation Commission?
'
Needs tobaobtu[nmd v�\ Obta�me� v�� 0atm �ssumd.
'
«�� x_� '
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 0 NO 0
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,or filling)over 1 acre orioit part o[o common plan
that will disturb over 1acre? YES K } NO Kl
~~� � '�/
/
|F YES,then a Northampton Storm Water Management Permit from the DPW is required.
2 ��Ctty of Nortf ampton ebmt
44ding Department ye a
D
Main Street
oom 100 or e� uatta�t l �
` Oj N rt am on; MA 01060 T°�r�Setso � �ratl? r � : 4
phone 4137W7-12 0 Fax 413-587-1272 Ptat l ans ���
.,.
AP TI6���TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
ea_
SECTION 1�INFORMATION
Thils section to be compieted byaff"ice a
1.1 Property Address:
yt) d 6 Q Zone Overlay icf
Efii St Distract "CB Distri ct
SECTION 2-PROPERTY OWN ERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) w Current Mailing Address-
-
1 $1
Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATM CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
Building 0� vl� (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
1 11 Construction from 6'
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This Section For Official Use Only
Date,
Building Permit-Number' Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
.1 A
60 SHERMAN AVE BP-2006-0146
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map. -.Block: 25A- 112 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0146
Project# JS-2006-0225
Est.Cost: $5000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg.ft.): 8799.12 Owner: DROZDAL MICHAEL&PAULA
Zoning:URB Applicant: DROZDAL MICHAEL & PAULA
AT. 60 SHERMAN AVE
Applicant Address: Phone: Insurance:
60 SHERMAN AVE Q 584-6408 (�
NORTHAMPTONMA01060 ISSUED ON:819105 0:00:00
TO PERFORM THE FOLLOWING WORK.INSTALL SIDING ON GARAGE
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 8/9/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo