25C-091 (6) �ASSAt�l15ttf5
DEPARTMENT OF BUILDDIEG INSPECTIONS /?
INSPECTOR
'212 Main Street • Municipal Building
Northampton, MA 01060
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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 l.is/her construction sup :,isor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or-two fam17y-
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 buil mg 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 eegulations. 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 noun 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
1H 4 understand the above.
ffiqkre owner/resident's signature requesting exemption)
I wt L&ll to schedule all required building inspections necessary for the building permit
issued-to me.
Daze — 2_3
Address of work
location
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DEPARTMENT OP DUIL-Df)\10 INSPP=011'S
212 Alain Strcet ' Municipal Building
?Northampton, Mass. 01060
_ VVOR=- R'S CONTENSATI0-N ENSURANCE AF , A TJ"
%VILh a principal place of businessfresidence at: - --
Z G �t�i� �C' �7• �CT�. I l�a tti, �n1 (I;nonc=-') � -3 n1
sa�t/ci r;/szatr.fa p)
do hereby certify, under dic-pz'M and penalties of perJ ry, hai
O I :man employer providing the following'%,,ori:cr's cofrlDCns_ntioi Coverage for Iny
emplovees 1vorJang on tilis job:
(I:nlran=Conr,::_a.•) (Polio: Niu bcr) — (r'=•piraaoa DaL_)
�(j I am a sole proprcror, general contractor or homeowner (c tie one) znd Dave hired
Lhe contractors listed below rybo liave the foUo%LMg worker's comnen_sadon policies:
V I�
(�Iamc of conIMCIO-) (InEurzZIC Compan)-pi ouct }` ) atc)
- .gum=c: ��:?i,-1n�;, D
— (N*nc of Conracior) (lsistuznc aMIDa.UV,Pol)Ci N'UJ 6Cr) (_Exoimuon Dwc)
(Name of Coaatacto,-) (Irsvranc; Compan}•!Pout}- Numb,-_r) (Expirraoo Daic)
(Name of Coaaaetor) (Cauca- Compzr y/Policy Number) ( xpim6oa Date)-
(nfI1C'11 ;;oc5.l rScC.ilnccc.�_-}•to incur inform:aoc pctn_aias to.11
O I am'a sole proprietor and bave no one worming for me.
I am..a home owner performing all the work myself.
NOTE:plese be eorzm rfi•• Jc � �wyo c=ploy peonz to r.b c=_—,xc a tray work as a dU--Z of
ant tncce t�.n L'-o—its is��i�the bomoowoc read.«oa the p,,,6 zpp,,x- .�tbe-eo i,ax Ccmr-_Uy oecid_cd to be
caVIcY=ante the" c=pc ,oa Act(GI2132,-1(3)).appU=L6on by.boa=%-=fc c b _cc pe-mit=y c�-dmoc tL�
lc9! of ea=Ploys under din Wk e,Coo�em...tio Act_
I—d'ro a d tit a oopy of tbi,mtcmcm t y be f.--rd o4 tc the D,9_, r o f In.& ri al Ac e_f'OIL—or L�-.00e for t6.
onYC►St ceirelioa and thu Lilt=tO snout:'=%%r Zt tmdc lc=on 23 A of MGL 132 m 1,--d to the iarp=id-dcriminzl Pcc%Wl=
mot-:i:xg of a tint of up to S 1 500.00 sndfcc ix=pr60==k=or up to coc yc_r and ci ail P=I.Pjn m 6c roan of a Slop Work Ord--nod a
(>�o(S 100-QO a d_y c�ia9 me -
M � •.,�.�,L.. I z, --i� •-o S Pt.rmil N�t� �.� - —i
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at Lic=s=_IPc rm it t nn UBCe I I
SECTION 8-CONSTRUCTION SERVICES t
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
S Re isteced Flotrite iri"ravement C6ntra or 06 .a- --"WO ,
Not Applicable 13
Company Name Registration um er - --"-
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE:AFFIDAVIFT(M.G:L,c.152,44 25G(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...... ❑
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onwo
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 aAd Local Zo ng Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature /�
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check allapplicable)
New House ❑ Addition ❑:., Replacement Windows Alteration(s) ❑ Roofing
Or Doors 171
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[1:3]
Brief Description of Proposed ' �9 VZ
Work:
Alteration of existing bedroom Yes o Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes __),�_No
Plans Attached Roll -Sheet
saw Ef Nevin hiwse��lc�arR�cfdi>��a� o�ex�stici�ioCrsrcicir''�of�gte�e�feo�IQU��na:
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 COMRLETED WHEN'
OWNERS AGENT OR CONTRACTOR-APPLIES FOR BUILDING:PERMIT
I,
as Owner of the subject
pro ert
hereby authorize
to act on my behalf,in all matters rsiative to work authorized by this building permit application.
r-
S6nalure of Owner Date
I as Owner/Authorized
AAd eby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
af.
Signed under the pains and penalties of perjury. '
4
Print N4me,
Cure of Owner/Agent Date
. ^v
.
'
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
Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume&Location)
A. Has a Special Perm it/Vahance/Findi ng ever been issued for/on the site?
x�~� �~� ^
NO *�� DON'T KNOW x~�/ Y[3 �~� '
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON7KNOW 0 YES
IF YES: enter Book Pag6 and/or Document#
B. Does the site contain a brook' body of water or wetlands? NO � DON7 KNOW 0 YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
'
Needs tobmobtained x~`� O�ta�mad �~� Om�e |ssme�' |
�~� v�� ' � '
��
C. Do any signs exist on the pruper�V 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
IF YES, describe size, type and location:
E Will the construction activity disturb or filling)over 1acre or isdpart ofocommon plan
that will disturb over 1 acre? YES K ] NO �M
`_^
}F YES,then o Northampton Storm Water Management Permit from the DPW is required.
CAy of Northampton of eata�
Reading Department _
' 212 Main Street � e t
Room 100 er eti= �e . j am
3 Northam ton; MA 01060 n Stn cfttr Tar
hone 413-587-1,240 Fax 413-587-1272 P� SIt 'tan ter*
s ' M N rI
Qftter
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This sectron to be conapleted:by office
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I��/L�'1 �m�I G� t ► �'! a Zone , 't,�t�. OvertayD�stncf
Etta St District CB Distncf
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZEDRGENT
2.1 Owner of Record:
Name Print) j / Current Mailing Address:
Telephone / q
ignat re 2
2. uthorized 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 Q r� (a)Building Permit Fee
2. Electrical O (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 Section For Official Use Only
,Date
Building Permit Number. 'Issued:
Signature:
Building Commissioner/Inspector of Buildings- Date
File#BP-2006-0592
APPLICANT/CONTACT PERSON SKIBISKI JOHN F REALTY
ADDRESS/PHONE P O BOX 381 NORTHAMPTON ()586-1827 Q
PROPERTY LOCATION 44 LINCOLN AVE
MAP 25C PARCEL 091 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
43uilding Permit Filled out
L,I`ee Paid $ 'U
Typeof Construction: Renovate Hallway and bedroom
New Construction
Non Structural interior renovations
Addition to Existing -
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INYF,0 MATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Permit With Site Plan
Major Project: Site Plan AND/OR Special Permit With Site Plan
ZONING BOARD PERMIT REQUIRED UNDER: §
Finding Special Permit Variance*
Received&Recorded at Registry of Deeds Proof Enclosed
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability
Septic Approval Board of Health Well Water Potability Board of Health
Permit from Conservation Commission Permit from CB Architecture Committee
Permit from Elm Street 'ssion
f
Signature of Building Official Date
Note:Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning
requirements and obtain all required permits from Board of Health,Conservation Commission,Department
of public works and other applicable permit granting authorities.
*Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of
Planning&Development for more information.
44 LINCOLN AVE BP-2006-0592
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-091 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0592
Project# JS-2006-0871
Est. Cost: $1850.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 8102.16 Owner: SKIBISKI JOHN F REALTY
Zoning:URB Applicant: SKIBISKI JOHN F JR & ANN H
AT. 44 LINCOLN AVE
Applicant Address: Phone: Insurance:
50 HASTINGS HEIGHTS
FLORENCEMA01062 ISSUED ON:1211412005 0:00:00
TO PERFORM THE FOLLOWING WORK.-Renovate Hallway and bedroom
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 12/14/2005 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo