25C-034 (6) 4'StSAA1P�.
$ � �1a3aac}�usetfs a ''-
DEPARTMENT OF BUILDDNTG 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,.: ,f sqr. T he state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two fami
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 fegulations. 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 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
F - Crii of �'Tarfljavlt}itoil
9 8 �Zasaicthns(tla' _
W DEPARTMEIJT OP DUIL.DI7\C INSPECTIONS _
212 Train Strcct ' hTunicipal Building
Northampton, Mass. 01060
«GIUC R*S C0,1MIENSATION GNSU -NCE AF�: «�~
(keens jpermittcc) - - --
%kllth a principal plate of businessfresidence at: -- — -
IWSS
� -
( city/sta.tL�a p)
do hereby certify, under the.paim and penalties of perjury, ha i
( I am an employer providing the iollowin ''x:orJ:cr's comocas_:Jo, Covemgc for Iny
emplovecs Nvorldng on this job:
(l.nsur-_n=Comm-) (:xpiraon D21`)
( ) I am a sole proor,ecor, general contractor or homeovemer (c tie one) and have hired
the contractors listed below vgbo have the folio%vino worke>'s coaoen-sallon policies:
(I amc Of Cont=aor) Gn--urznc Cof pin)'/PGUCi �1t1II1LC) °d 3^ D.-Itc)
(Name of Coamcior) (instuzncc Compaq -iPo1e: `uncrr) ��-piradon Datc)
(Name of Conn-aclo:) Gasur cz Company/Polk}• Nambu) (Expiraoo Datc)
(Name of Coaaactor) (Insurance Compafry/PoUcy Number) (Expiradoa Date),
(ans[.3-'d6i:0cci�cc.,tfncr_ca�•to atdu'&iafocaajon=ng to.0 co=--=0o. )
O I am a sole proprietor and have no ooe wori,-ing for me.
( ) I am,a home owner performing all the work myself:
NOTE:plea be ewzrc tbx o j;•to hem=%vcn utio csploy pczam to do_ ^^- rgair work an.d"r[1_E of
ane mocc th-„tt=ac taitt is ujneh the bo=o ramdo or oa ttx pvuacb zppurtn theca LT ooe C•oa--Uy ooc:dcrcd to be
eiVIOo z t] fr the-=k=-.rr�oo Act(GL'152•=t(5)1 =pptinbon b-f a hc=m o-va far a fib_or pamit rt:y--id—the
1cgJ ctaaic area-=Play-under dro W.-k e.Compomatioo AcL
[undaaaad tha a Dopy of thi,-= may be foe�to tbu Delta u—d of Lady id Aeodenay Oaioa of 4aw'+nee rot th.
nova a�C reriCatioa aad ttu Liltae to so�uc tovornbz undo section 23A of ht4L 152 can ltd to the i-npos2ioa of crimiast pccilw'=
000si.ZZ3S of a riac or UP to S 1 00.00 and/or m�e of up to oat yes e.od a\•U pca.hia in tSc form of a Stop Wolf;Order and° -
rt=of S 100.00 a d.y L&zinst me_
_ F«dcgaca+�u, only .
Permit Numt
]"/Lap--- Lot Y
Sipnattim of Lia=iscrJPcrmiucc Cate -1
SECTION 8-CONSTRUCTION SERVICES '71
r-•
8.1 Licensed Construction�S)upe visor: Not Applicable ❑
Name of License Holder: W 1, k", Qf�
License Number
1P O. -8 yy ,Iy //a.d4e y. r"c�, Old Ss' 0/�7;21VG1
Addr Expiration'Date
A Signature Te pho e
� _ �
:114 rstered'Hamelm ravemenl::Con racfor:,= Not Applicable ❑
/ FT
---------
Company Name Registration IVum6er --
William onaLek U6 --ef-
- d6
Address ( /j�,�y� Expiration Date
1?6. Bd 0 Q�� YI1 6/UJ rTelephbn�"d o S� �1--
SECTION 10 WORKERS'COMPENSATION INSURANCE AFFI.DAVIT'(M:G-L.c.'152,,§25C(S))
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....... 6 No...... ❑
11 >�T�"= �ip�i
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
r
i
a
SECTION 5-DESCRIPTION'OF PROPOSED WORK(check all applicable)
New House [] Addition ❑.: Replacement Windows [Alteration(s) ❑ Roofing ler
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[0]
Brief Descriptio of Proposed
Work: &
JV
Alteration of existing bedroom Yes o Adding new bedroom_ Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa I_1'ke -�o�tse�and=or ad'ditiQ o exi IS4�ioust cr::cor prate th fa�t6ur ing:
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?
Y d. Proposed Square footage of new construction. Dimensions
V 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-70 BE COMPLETED WHEN
OWNERS AGENT OR"CONTRACTOR APPLIES FOR'BUILDINCr.PERMIT
�LJ67 as Owner of the subject
property �i
hereby authorize �/ .�-�l��t On a.�0,,t
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signaturd4f Owner Date
I, y" !i !Q 1'►1 C�-I1�2 1 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.
Gtr/L�/A•�� /�,' 7Z"e
d Print Name
Signature of Owner/Agent Date
Section 4. ZONING All 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
Side Li R:{ I
r' I
Rear
nj i r] Building Height �-
Bldg.Square Footage '— s
Open Space Footage %
(Lot area minus bldg&paved i_-€ [ ��
narking)
�- 7-7
i
#of Parking Spaces i
Fill:
(volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO Q DON'T KNOW YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON'T KNOW 0 YES 0
IF YES: enter Book 1 Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO ® DONT KNOW Q YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Date Issued:
C. Do any signs exist on the property? YES 0 NO 0
IF YES, describe size, type and location: s
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.
P
City of Norte ampton
—�B�uilding Department het e a
'.212 Main Street Sewers
Room 100 Uater�llel�Av :
rt�ampton- MA 01060 Set rc7��ans
JuN 1 3 e�5 7-1240 Fax 413-587-1272 Ptah It ans� " 2 �
L.APP 1, ";T.OiCQNSTR T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
TION
f-SITE INFORMATION
. - Thrs.sectran,to be cgmpleted'by office
1.1 Prropertyy�Addre>ss: g
e `►'1 1/2 Matz Lot Ur�rt
iz
A/0?4h Q rnp y,.,, I )'7'1(,L Zone Overlay Qrsfrrcf
sr f Dsnt E B D st
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(Print) Curr nt Mailing Address:
Telephone
Signat
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 Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) Q. en" Check Number
This Section'For Official'Use Only
`Date`.'
Building'Permit Number. Issued:
Signature:
Building Comm issioner/I nspector of Buildings Date
27 NORTHERN AVE BP-2005-1227
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-034 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category. PERMIT
Permit# BP-2005-1227
Project# 35-2005-1645
Est.Cost: $6500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use croup: William Gnatek 1.00088
Lot Size(sq.ft.): 10018.80 Owner: BLACK BARBARA L&JOEL
Zoning:URB Applicant: William Gnatek
AT. 27 NORTHERN AVE
Applicant Address: Phone: Insurance:
P 0 Box 204 (413) 584-5682 WC
HADLEYMA01035 ISSUED ON:6113105 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE PORCH ROOFS
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 6/13/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo