25C-091 (9) O��t1AMpjO
Clity of Xort4ampton z
$ 0 ass a chits etts
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 l:is/her construction supe-,"A 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
understand the above.
(H me owner/resident's signature requesting exemption)
I call to schedule all required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
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m 1)EPfiRTT,fEN-F 017 LUILDDJ G INSPECTIONS
212 Main Street ' Municipal Buil(Eng
Northampton, Mass. 01060 0,
NVORKER'S COMPENSATION INSURANCE AFFIDAVIT
I,
th a principal place, of bus,r.ess/re:;iCence
do hcI'cby Cert>1)`. 11:K'cr tllc• P lnS �'_no pail:ides of 'iCrJtll�r, '.flan. -
i
( ) I a.m an c:iap?oyer providin- the follo.`.'int .vorr_cr`s compc!ISat on covcra c or my
employees W06dlig on t?ris job:
(Insuancz� Company) (.c_;�c;NumExr)
( j I am a sole proorit tor, genera conk o; hor,_eo,,-,,Mc (circle one) and gave, nir d
the contractors listed beiow-,;ho toll �,'Ori<,ers cor!penS _ion -ol e s:
('Mama of CoilLm aor) c{ wtu-nt-_ iiX ri:CC' Datc)
(Name of Cont?-:cto") Olhsur,]nce com:Dr:rvfpc.hc,' Nt r tr r) tlorl Date
(_Nlamc of Coat-,-.acior) rins lc� Co L - -- r. -
� .,.;;Folic. Nur t;_r) -- -^s: a.�lai�cj
-- (Name of Contrtctor) — (Tas'JauiC- Com- _,�,fPolicr Numb-r) - (L: -::for Date)
C_ t�[Tl 1. OIL 1)I Up 1 Ji 2':i!tl hav-1- I70 OI1'� ,','UC��lii'�{ fo1
110I11c CA,'il iiG'rr„r1n1h,; all t.
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z;a 14"'11 in.-c.
not uxYC lr a throc Lan's in Iii.ch u /x;' :,:s z V'rtcc r1 Lhcc o c 2 cx{0crr 11y o:r::::::: :o tti
A_c,(GL!52,:x!(5)';,r :ic:;t,y a hn:aco. xr.`•cr e
h
ItGal ctau ofan cloy' un' tho Wo i;cez n coitio
I un ic_rztand thL a copy of Lliv ",-Y bo fcx 'nr 10-1 to I!» OM—of for tlx
cova-&&c waif c+lioo aid that f:.ilurc to cc`....c coscr ut;3::scciM 25,q of?.1Gt,1S2 can lc---d to tho inirasition
eomisting ofa fur_of up to S I,SCK OO nn lc,(i-::nr x=ti; of::p to cr.: evil pernriics in c icmn of a S:c-,+`;y'nX C} a_:f
fin,-of S I00-00 a day i .in l m.
e c c d w;uvTrztal u,c c'il}'
Pcrrnit NIIIIAr:r
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SECT30N 8=CONSTRUOTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
9Regisere lmro�re`meat Confracto=. �, _ MM
.-RO Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M:G:L..c. 152,§ 25C(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 buildine 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 G�
SECTIONSDESGRIP,�TION OF PROPOSED�M1IORK(check all applicable) a "
x,,..k'i
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ JRoofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding[ ] Other [�]
Brief Description of Proposed Work: uaw f�XSIsl`� (Ytc e� f °
Alteration of existing bedroom Yes X No Adding new bedroom Yes x No
Attached Narrative 0 Renovating unfinished basement Yes x No
Plans Attached Roll O - Sheet❑
6a TENews=h:o"use ndtorrr dd"itionao7ezisting'M0UtiffVk Mete the--foflMM:
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. bimensions
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
SECTION7aQINNER AUTHORIZATION Tb BE COMPLETED WHEN
OWNEFtSAGE NIORCONTRACTORAPPLIES FORsBUILDING PERMIT=
- -
as Owner of the subject property
hereby authorize to acs on
my behalf, in all matters relative to work authorized by this building permit application-
Signature of Owner Date
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.
Print Name
ig ture f 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 '� 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 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:
City of Northampton - � �
Building Department ` ""
-21 Main Street ��
leg
Pton, MA 01060 a s E
? i
phone 413'; 8 -1240 Fax 413-587-1272 . ��
2 8
A tPLICATION TO CON.SUUCT,ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
T its section to he completed by office
1.1 Property Address:
tot Unrt
No,n il�i I v►. Al A Zone Overlay District ;
Elm St.D�strsct CS Disb'iet
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
MA o/o�
N me(Print) Current Mailing Address:
Telephone
gn ture
2.2 Authorized Agent:
-J6I� �, S '► • s i � o . 73Ur 3 � �� �iu�,���,, CIA
Name(Print) / Current Mailing Address: T
M1, . S � s 1 /
S gna e _ Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building IF S 9 -(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 = (i + 2 + 3 +4+ 5) Check Number o�
This Section For Official Use Only'
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-1330
APPLICANT/CONTACT PERSON SKIBISKI JOHN F REALTY
ADDRESS/PHONE P O BOX 381 NORTHAMPTON `J'A'
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
Building Permit Filled out
Fee Paid
Typeof Construction: REPAIR EXISTING FRONT PORCH
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 F,RLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFPRMATION 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 Co ion
"ff�,q L low
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 Lei -AVE BP-2004-1330
GIS#: COMMONWEALTH OF MASSACHUSETTS
Pv Va.j�k:25C-091 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit# BP-2004-1330
Project# JS-2004-1999
Est.Cost: $2250.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa. ft.): 8102.16 Owner: SKIBISKI JOHN F REALTY
zoning:URB Applicant: SKIBISKI JOHN F REALTY
AT: 44 LINCOLN AVE
Applicant Address: Phone: Insurance:
P O BOX 381 O 586-1827 O
NORTHAMPTON MAO 1061 ISSUED ON.6/30/04 0:00:00
TO PERFORM THE FOLLOWING WORK.-REPAIR EXISTING FRONT PORCH
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 6/30/04 0:00:00 5655 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo