25C-051 t s
��HAMpl,
Crzfy of Wart4a ptan z
t
�1111H558Ch118[tts '
DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR 212 Main Street • Municipal Building
Northampton, 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 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
required can DELAY the project until such time as the proper permits and inspections are
made
I, understand the above.
(Home ow er/resident's sign ture requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
{.0 -
I ( lip >�f lrz �lJciltt c�1t TMW.
T
;it&S S ACil 115 C I IS
1)UARTMEN'T OF EUILDDI G INSPECTIONS
212 Main Street ' Municipal Building 'a j•
'Northampton, Mass. 01060
WOR CER'S COMTENSATION INSURANCE AFFMAVI.T
a priucip,- place of busMcss/rts'lc Iac
do hereby cc�ify; urlccr tllc pa:cis ,Ind pen;iti n p::rjury, ti?a:.
( I all an employer providing the f0f10'.':iI1C_ '.z;QI'!Cr 5 compcnsfC101] COVC: : C '01 Iny
employce.s working on this job:
jns =c- Corapam•) clic;NumFxr) ---- (rte�iraon Datc)
( j I am a sole proo;ietor, genPTat C-cutnCrCr G" t?omcowoer (circle one) and Have, hired
the, coI]7actors listed beiovv ,.hc, tilt. LO]C t,-•,- � ' Pr'S Oli S:
_ orl� cot: pen� �on .
(Na= of Contrlctor) (ri-su'nc:. CoIP^";:Tr'-Tolicy NllIIIb--7) + ?'' .t..ICG Datc)-
(Name of Contrctor) (Ias mmce Dave)
(Name of Contractor) (Ins �s]c0 Cou m,;Polio. Ntllnlxr) =.z; do 1?ate)
(Name of Cont:zlctcr) — - (Ins rai�c� Coil]? };'Policy Numl;ir} (Ex I :Ilor Date)
(etL�dt-.d�iticeal S':'Ct:I I:C.^tC•a.^:::�:.r...�..�...:.:K:C:a::Ct:i L.-.... - el.•O:G::_:�i:f'�
1 1<LIl it :;olC 1)1 Oj?I1Ct ?i r.illl ;li?'.'C i?O OI: CCU i''' for nn?
a home
C1'iI]C� 'tiCt.' `1I11I? 11( L: �'�'...... .
HOTF:p(casc L%c awn:c t1:zc:.tt•]c FK<;< 1Y S +;r�r, pi ;r. -: n;t> zsancc Cr. m Cr
not uxre tit n 4tue0 uni+s in
tit ez he 1 ;,i r re: a;` _.,_s z •, ez_r1 hie o=c rx:t
cznployc3 u_tir,cr 0) tvcr,z s ar °rn z t (GL!52 :(Sly :ic: y s hncaro« r`cr n c-.c cc
Icgal ctatu.of rn=plo)w under thn Wcv Xer't Cc ;o rsl:an?.cL
I undo::and that a copy of tha cEitc: ^•r:ay bo fotwnrci J to tln Am,'--z&oirca for tmx
covaz&c vrrific:-:10a and that fzaluze to:-_+^trc c'G* -r_;„uzd,—z s4c,icct 25A d i.toL.152 r-in 1u.1 to the im siiio.•�o;c: i::.!pct:ilr.:s
cocnistring of a fur-of up to S 1.S -00 n: .'Y i lrt ^i C::of tip to cr,.}- !:.1 civil()CM160 in d�Ic,nn"f.,S!r.,`;Je is(}r:=_:A
f rm oC S 1 00.0<3 a dsy i .:in:1 m.. -
- roc'cir�%riuta-i e>.1 urc only
Signature o T-,
f _
iccnrzJl crnr,:mc:.
S11CT10N 8: CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder :
License Number
Address Expiration Date
Signature Telephone
Rein s e're orne mp�o�rement`Contracto ME Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SEGTION 10` WORKERS' COMPENSATION INSURANCE AFFIDAVIT 152,§26,C(6
z _..
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"homeo-,vner" 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.
J Homeowner Signature
ni
SEGT{ON DESf R P!7�tONVflFt ROPOSEQi1W0RK= chec1ta�I a lica le
_.
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[[ ) Other [ ]
Brief Description of Proposed Work: tQ
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative 0 Renovating unfinished basement Yes No
Plans Attached Roll 0•Sheet o
a, `< o sera d or �. d,i.tionnto existinghotaing�comp °e#e tiefollowin
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. Mascheck Energy Compliance form attached?
In. 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
SECT�Q� NERAU �ORlZA7ION TO BE COMPLETED WHEN
OWNEC{,5gEN1000NTRAC70R gPPL1E5 FOR BUILDING PERMIT
I' 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
✓ I t , as Owner l.Authorized Agent
hereby declar that the statement nd information on the foregoing application are true and accurate, to the best of my
knowledge a belief.
Signed under the pains and penalties f perjury.
S (e V-\�`=A
Print Name
Signature of Owner/Agent Date
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:
I y of Northampton
Q b'Iding Department
12 Main Street
Room 100
rth mpton, MA 01060 e
ocGTi�O -58 -1240 Fax 413-587.1272
Qf 81!t10�NGINA pl.... CZt)her <u
TION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This secti.otot om tteciti ffice
1.1 Property Address:
k �� � a
4 L n c o/k.)
EImSL Disfnct GCBD�stnct ,
SECTION 2-'PROPERTY OWNERSHIP%AUTHORIZED AGENT
2.1 Owner of Record:
4/. /ice Pqyo--
Name(Print Current Mailing Address:
IS76141 IQ
Signature Telephone
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTlON;3 - ESTIMATED CONST.RUCTIONxCO"STS
Item Estimated Cost(Dollars) to be Official Use'Omly
com feted by ermit applicant
1. ildi q'n (a) Building Permit Fee
2. Eleciric (b) =:stimated Total Cost of
Construction from 5
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
Building Permit Number: Date I"ssued:
Signature:
Building Commissioner/Inspectorbf Buildings Date
59 LINCOLN AVID BP-2004-0319
GIS#: COMMONWEALTH OF MASSACHUSETTS
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category. BUILDING PERMIT
Permit# BP-2004-0319
Project# IS-2004-0466
Est. Cost: $0.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 12501.72 Owner: BEDNARZ STANLEY W
Zoning: URB Applicant: BEDNARZ STANLEY W
AT. 59 LINCOLN AVE
Applicant Address: Phone: Insurance:
59 LINCOLN AVE
NORTHAMPTON MAO 1060 ISSUED ON:9119103 0:00:00
TO PERFORM THE FOLLOWING WORK.STRIP & SHINGLE 1/2 OF HOUSE & GARAGE
ROOF
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 9/19/03 0:00:00 424 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo