25C-053 (4) p¢�HAMp�o
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DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building
�y See`
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 supc;-,•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 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
1, 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
bee i� L
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s m DEP!'U2TMEN OI' BUILDING INSPECTIONS
212 Alain Street ' Municipal Building
Nlorthampton, Mass. 01060 ' e,
WORKER'S COMPENSATION INSURANCE A + T-DA IT
(liens^c�'�frtnittee) -
:ith i prineip d place of business/residence
- -- ( S r' !e t t?t� --- - - --------0 --3 —-(�ho n c-;----
do hereby cer[iiy, under the pins ililc pen1i'Lic", of perjury, ttniaf:
( ) I ara an employer providing the followim-, -vorr_crt compensation cover- e [or Iny
eluployccs `Vorldlifg on this job:
(Las-, .nom Compam) (Pclic.Nurllber) -- (Es r lion Datc)
j i am a sole prop ietor general c-�n rac or horleo�Yner (c4 Cle one) and llav hire d
t.li:', contractors listeC beiovv v,!ho i t a(: f01 1 :viP.? 'tilOi tte�S GJu peIl 011 ^v!iC!�S:
(2:IISnC of ConL'1Ctor) (1ns'=-nc Datc)
(Name of Contrac.o:) _ (1rZj]r rc Comn_.lv�Po!ic; Ntrl r) (l :p -tioa Date)
("'ame of C-oatnclor) TnoD Datc)
- (Name of Contractor) — (Insl.tanc� Come .y/-PoLicv Numb---r) (F:;:r,.!::uco Date)
(^(.aL1 a.dditice:�l zE'._et i..'_-.... t:�:.-_.a.- ....<r:^.a:•.u:�t._.... efi..r.-..._...•)
1 21111 t; OlL proprlC': )i c 111 ill?V 110 011,13 :U' ii` t0i iI1
iIl 2 1:011?e C)tit+?1C: iiCr:C;`I111Ii ?ll iL il:'r; 1.
ar:::.:c m cr::pair w,,,y,
NOTIi:p(cau be nw•1:c t}s:'.r�.:i)c fr;,co���r.:�.-,.�r-P.cr�,>^_=.��::����-_t;;�.acc. '_ �• .
not crtoce tho throe uniU in hzr�n :'.i i- r :: J n Cc '_:. z L'=I cr a it---toe e n<cCrr211Y ar:::,:::u:o
1^-1P10yc-3 u:r er the wcc refs Cc!7--s un tc (G1L152-::a 1(5)1.n,;iir..:ic::'nv n hotn:o«-xs for e Lccu cc F ra:i:r. - r e th.
legzl ctattus of an o=xQloyor under tiro Wcvkoez<oi;-:.lion?.cc-
I und=zt...nd IhL a co?y of thu etatc--4 n: y bo fcww,ucirl to tb,fYtiervx,c:L of lr>du.,j-1 Acci&�,f Cf i of for Llx
oovcmg,-vaifiCiion ynd th t f ilurc to t-- e 25A cf,1,01.152 cart lc--d to the im{-Dsitiat f r ir_1 ptt�L:ts
oo¢zuting of a fur_of up to S 150000 an:l'cr i-:Iir, z of::p to nr.:}: r.:.f Civil xruil u in do fnnn of n Sty,`:'ai.On"cr--rd s
fim o(SIOO.N a day ins-iw,,t tn:.
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Sltn. Lure of:.icon:- • Pcrm;ac�, _ _ '''"
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SECTION 8=CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
S l J a D ka-c D y C C_( a- Cl L 3e ( r
Address Expiration Date
Z -d Oi
Sig Telephone
� " Not Applicable ❑
Regis e�""e �F`i`om�e lmoro ementsContracto *-�-
Company Name Registration Number
jC% o f33
Address Expiration Date
Telephone
SECTION 10' WORKERS'.,-COMPENSATION INSURANCE AFFIDAVIT(M.G:L. c. 152,-§ 250(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...... ❑.
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
'" x; Ott. E S R PTOTIIfOF�PROPOSED WORK check all a I�calile
RP
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks
[ ) Sidings) Other [ )
Brief Description of Proposed Work: Sc� t'7"
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll❑ - Sheet C
sa f ffl ouse nd or a�ii:i-#f.on to exisfing housing Complete the fol7owin
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?
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
SECTIOK7OWL�ERAUORIZATION TO BE COMPLETED WHEN
OWNEkS AGENiORCONTRACTOR APPLIES'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.
y - 15- oaf
Signature of Owner Date
area r/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 i
Signature of Ow A ent Date
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE DENIED
DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
Ibis 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 DONT KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DONT KNOW YES
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT 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:
City of Northampton
Building Department
212 Main Street
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
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APPLICATION TO CONSTRUCT,ALTER, REPAIR,RENOVATE OR DEMOLISH 4110 NE OR,rAfQ•T _iLY DWELLING
r
SECTION 1-SITE'INFORMATION t L
This s�ctwn to fie
¢¢¢,, completed by o ice
1.1 Properly Address: �R� 4
co(-to hl � Map' �Lbl1It n
4
��-�,m any plc(8 Tone
'V' 'day DisMct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
2,P 7 ` Kv�-�e r r •� �- ;��, ,ter
Name(Print) Current Mailing Address:
t 2� Telephone A1. 1,3
Signature
2.2 Authorized Aae�nt(:
W Dt�t7 2/,V iC7 C w,
Name(Print) Current Mailing Address:
`1(3`a-y-7—'1 o� �
Signa a Telephone
SECTIO ESTIMATE ONSTRUCTION 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 lPermit-Fee
4. Mechanical(NVAC)
5. Fire Protection
6. Total = (1 +2+3+4+ 5) Check Number
This Sectiai For Official Use Onl
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
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51 LINCOLN AVE BP-2004-1062
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-053 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cate o� r . BUILDING PERMIT
Permit# BP-2004-1062
Project# JS-2004-1586
Est. Cost: $1000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: John Zieminski 100133
Lot Size(sq_ft.): 10062.36 Owner: MCKEEVER JAMES E&PATRICIA F
Zoning.URB Applicant: John Zieminski
AT: 51 LINCOLN AVE
Applicant Address: Phone: Insurance:
8 WOODRIDGE CIRC (413) 247-9014 Workers
Compensation
HATFIELDMA01038 ISSUED ON.4/30/04 0:00.00
TO PERFORM THE FOLLOWING WORK.-REPLACE 500 SQ FT OF 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 4/30/04 0:00:00 5139 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo
51 LINCOLN AVE BP-2004-1062
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-053 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Cateaory: BUILDING PERMIT
Permit# BP-2004-1062
Project# JS-2004-1586
Est. Cost:$1000.00
Fee:$25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor. License:
Use Group: John Zieminski 100133
Lot Size(sq ft.): 10062.36 Owner: MCKEEVER JAMES E&PATRICIA F
Zoning.URB Applicant: John Zieminski
AT! 51 i INCC N' e VF
Applicant Address: Phone: Insurance:
8 WOODRIDGE CIRC (413).247-9014 Workers
Compensation
HATFIELDMA01038 ISSUED ON:4130104 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPLACE 500 SQ FT OF 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: Q K lbw
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS. G
}� J
Certificate of Occugangy si nature:
FeeType: Receipt No: Date Paid: Check No: Amount:
Building 4/30/04 0:00:00 5139 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo