25C-083 (2) ¢�8AMP1.
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DEPARTMENT OF BUILDING INSPECTIONS f?
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 his/her construction supc-,•i sor. T he state defines"Homeowner" as, "Person(s)
who owns a parcel on which he/she resides or intends to be, a one or hvo fame y
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 ofNorthampton wantsfany persons)who-peek-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 buildine 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 insaected.
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
L 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.
Daze
Address of work
location
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R}o p E GIN) p ��LtL" I�alll}7�OI.1
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f .61cyaRr}Inrclln-
j DEPART}4E1fT OF I3UILDD\10 INSPPCTI)ONS
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212 Train Strcct ' 'i\ I pnl F3ttildIng
Nrorlhampton, Mass. 010GO
t 'ORICLR'S CONMIENSATIO.N G�ISURAhCE AI'IT�r .VIZ
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�azth a plincipal place of businessfresidence at: — -
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(sa-G.t/ci t`J/SZa1cf a p)
1 do hereby certify, under thc.pains and penalties of perjury,
{ ( zsn an employer providing the followin>;hvonccr s comDCasanon covera ge for Intl•
etnplovecs %vorlang on this job:
(Lsu.r�=Comr.may) lPclic:?tits r_r) -pirlior. D2=)
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( ) I am a sole proprcror, general contracor or homeov�-Oer (c cie orle) z.Dd h2ve hired
the coouactors Gst°Ii below r,,ho have the follotvinQ workers comptp_,,26on pokles,
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(N=c of Contrac-,Or) (InnII-ancc- CoInpwi},PPGUc-i (i-:)U jDn Datc)
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(N;mc of Concamor) (LslranC COMDan-VIPOUM' NUM Cr) (L»tr6on Date)
(Na me of Co=-aao:) (l.»u-ancc Compao)-1PoGcy N:urb,-j) (Expiraoo Dalc)
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(Name of Conn-actor) (Irsura Comp y/Policy Numb:r) (Expi m6on Datc)
(aC]c'3 aG1 oval s3ca.ilacaaa_�-to iacud=iaforzsn�oa pctn.ia�to aI1 ooc-�.oz)
1 { ) I am a sole-proprietor and have no one worlti.ng for me.
( ) I am,a home owner performing all the work myself.
NOTE:plr=u be aw-srr o—w;-}e bemewvera..i o c=play p�=.om w 4, : • c=,.rro a rtpzr.,ark os a d..<n:..`or
Jnn(taaoce tb-m a=ra in«1sch the bo�roach or oa the Vroun6 zp�tbc-, r o-x ->r�ty a�cd-ai to be
c=rplc)--z the..xi r c-Y--..:oa Aa(G L15Z=1(5)x=Pp1i=6vz try a bo. f=c bG_oc pcmit=7 c.-id—tIv
Icgal c"^„of na c-rployx uad r dun Workve-Com�o Ae(_
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[uadCT.�,ad thaw oopy or thi.cstemeax may t- to tha D,,.�of IndKSriJ Attars'Dm-or t—for th.
. --4e a v=Ze=ioo am ax--E Eli=to cC=M Oovere o^e tmdG sreeion 25 A of MOL 152 as lr to the i:=Pcd6oa of c=im;czj peailtio
cocsisi=g of a fiat of up to S I}00,00 andfOr im;riaocn=k=orup b ooc yc =d 6vu pm.tin io tSc form or a Stop Work Ord--nod a
5m of S I DO-00 s d_y cpi=CD,-
. - For dcvartrx�=–sI u.c only - .
Pcrmit t�(umbcs
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��p= Lot
Sig laWIr of LialscclPcrmiUc:. e
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SECTION 8-CONSTRUCTION SERVICES f
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
�a
-7Keats eTe� ame nipnrc verve n rac/Ia „ Not Applicable ❑
U) -Li Q m c na (�,�7�1 l J r /oD4
Company Name Registration Num er - _-
Address f
Expiration Date
Telephone`
SECTION 10-WORKERS'COMPENSATION INSURANCE,i4FFIDAVIT(M:G'.L c.'f52s§2sC(t))
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...... ❑
a
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 Annot#ted,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
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SECTION 5-DESCRIPTION'OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑:: Replacement Windows Alteration(s) ❑ Roofing
Or Doors 1:3
Accessory Bldg. ❑ Demolition ❑ New Signs [E3] Decks [0 Siding[0] Other[CO]
Brief Description of Proposed n
Work: tLi"4 Inc-'
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa INew=F>io rcdin oexnc> ioasn :ar'x ' HIRE
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a--OWNER AUTHORIZATION-TO'BE COMPLETED WHEN
OWNERS AGENT-',OR CONTRACTOR APPLIES`FOR 6W0ING]PERMIT
I, I-o.5,epA h 1 eL e e as Owner of the subject
property
hereby authorize �l .t 1`�m �/12 e—
to act on my behalf,in all matters relative to work authorized by this building permit application.
Si ture of divner Date
l Lo j k4 a yll 6?n Lt 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.
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p Print Name // �s
Signature of Owner/Agent Date
Section 4. ZONING All Informatibfi 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 I -
Frontage I i
Setbacks Front I € —
Side L, = R:= Li R:i '
j� Rear
Building Height
Bldg.Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
arkin
#of Parking Spaces
Fill: '
(volume'&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DON'T KNOW AM 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 Page; 1 and/or Document#I
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES i
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
E
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 r NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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<< CityOf Northampton .
'Buildi6g Department
2 -2 Main Street
Room 100 t
.1 Northampton; MA 01060
phone 413-587-1240 Fax 413-587-1272
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APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
x Thi sectioty e compld by offi1.1 Property Address: t
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G 9 �67, = 7p� � UntL
Zone
Overlay Dlstncf
�Elln Sf."`DlstrlCt '�W� .:,. C6 Dlstnct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
as h kel ec
N me z Currey Mailing Ad
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Telephone 7
gnature
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 Costof
Construction from` 6'
3. Plumbing .Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection `
6. Total=(1 +2+3+4+5) c,16fJ. Check Number
This-Section For Official Use Only
Date
Building;Permit Number; Issued:
Signature:
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Building Commissioner/Inspector of Buildings Date
P •
319 BRIDGE ST BP-2006-0516
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:25C-083 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2006-0516
Project# JS-2006-0764
Est.Cost: $1200.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: William Gnatek 100088
Lot Size(sq. ft.): 130680.00 Owner: KIELEC JOSEPH W&ANNA M
Zoning:URB/SR/WP Applicant: William Gnatek
AT. 319 BRIDGE ST
Applicant Address: Phone: Insurance:
P O Box 204 (413) 584-5682 WC
HADLEYMA01035 ISSUED ON.111712005 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP & SHINGLE 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• Date Paid: Amount:
Building 11/7/2005 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo