25C-251 (61) oggtlAMp�o
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_Grify of Northampton
$ � jltrZassacftitscffs
DEPARTMENT OF BUILDD,,TG INSPECTIONS /
INSPECTOR '212 Main Street • Municipal Building s �'
North,-unPton,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 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-ami 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 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 r',egulations. 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 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
j R E (riff Pf �,TRrf12u11tpjo)t
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v DEPARTMENT OP DUILDf?\)G INSPPCI•IOI:S
212 Main Strcet Nfunicipal Building
Northampton, hlass. 01060
WORKER'S C(DKPENSA IZON CiSURANCF AI,=riVI7
i
i 1
.As s 4
%VILb a principal place of business/residence at: --------
q 5 t /g 111 (phone') WI-636-3
(st�tici ty/szalthp)
do hereby cerdf--, under thc.pains and penalties of pcfJury., :hat
I .
( ) I am an employer providing die followine'worl:cr's comoc)s-bon covemgc for 1n%
elnplovees `vorldng on diis job:
(La=a =Compz--m) (Po Li c: Nu--z�-r) -- (r:•pirz on i7.aL--)
I -
i ,
( ) I am a sole proprietor, general contractor or homeowner(crc;e one) and have hued
the conaaclors listed below who h2ve the following workers caMnen_tadon policies:
(i;=c of Co„Mczor) (NnR rant Colnpan}'fPGhci Nlumh---) �_XJIidGQn ��]lC)
(Nzmc of Contractor) (lrlsurancxx CompanyPolim, Numcrr) (Eipu-aiion Date)
j (Name of Conlzacior) Qnsufane: Comp2zy[Polio• Numb--j) (Expirtioo Date)
(Dame of Contractor) (insuran(-- Comrar y/PoLicy Number) (Eapitation DatL) .
(atu.cb 'ti�ocSJ c3ca,ifncc�i�•to induct uifocma�oo;_p to.11
I arm a sole proprietor and have no one worl;3ng for me.
( } I am,a home owner performing all the work myself.
{ NOTE:plea be tcrzre tfi,•..tJc 6emco avcn u1, employ pc-Lam to cii i� oo a mpur-ori:on of
aot anct t�.n t:zw tram in%cinch the botaoowver nca da or oa the pmux, rt.-s zpputtca=tb.- o t-r ox C•.. =Ily oc-=d,--vi to be
to uoC-the�.
� �? y� -i:rfa c=.,-x----+on Ac=(GL1152.n t(S)�=pP[iabon by a bomma-D=fQ c Gcx.or txzmit c=y cidmec t1:c
legl n--u of as =Ploy,.&,tae WGA e,Co�oa A&-
i
I undcszcnd taa a Dopy of tai,mzcmam may be r«—ni.e to tbo Dryucmms or 1.,&X c!A—d-d office ur t,av+oa+for tLe
covcasc cif olio°a rd!hs lzi1LTC to so�uc tcovct a�undo wcLioa 25A of h(GL 152 m Ir_d to the i p� oa of aimi=l pedalo=
mom iriag of a tine of cep to S I Soo.00 andfor i3 iyo�of up to ooe y==tad 6N-a pcaahio in 6c form of a Slop Work Ord-and.
fi=o(S I0D.00 a d_y apjnA tnc
fx dWu�u.c only
PC'rIII7l)`luIDt7C.7 _
✓ �1 � ��-- Lot ° ,R
i tlxaturr Lic=x-- r Pcrmiucc Date
1 •
SECTION 8-CONSTRUCTION SER)/I,CES f
81 Licensed Construction Supervi'-syyor://1� ~r Not Applicable ❑
Name of License Holder: 1 GlP J 1 J�V f! 0'S zol r
' License Number
M 4 01(J6.0
Address Expiration Date
l/-G3G 7
signature Telephone
r
Not Applicable ❑
lea she e� o�ei�pra�rmer°t 'ontra�t� _ ,�
,?GP '� �sa NSA ► � lc�C GAG
Company Name
Registration um er ----"
1
l)
5 ��!� )4 Tilt'
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION-INSUMNCE AI=FIDAVIT(M:&L.c.152,,§25C(0
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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The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
and to allow such homevwuei 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-vear 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
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SECTION'5-DESCRIPTION?OF.PROPOSED WORK(check all applicable)
New House F-1 Addition [❑: Replacement Windows Alteration(s) ❑ Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [Q Siding[0] Other[p]
Brief Description of Proposed `
Work: nVe 1'/li-!/1 ��57�// /r��t// fi'-/(,1 /7;f10/ptI
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
saw- l�iewh`"use�a"ri rcl"di��ia awt x><s#In��-Iic� stn_ � omgie�eft auvl a:
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,QR CONTRACTQR APPLIES FOR BUILDING.PERMIT
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 'C )
as Owner/Authorized
Age hereby decl a 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
gnature of caner/Agent Date -Gl
~
Section 4. ZONING All Informati6h 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
(volurne,&Location)
A. Has a| Permit/Vahancs/Findi ever been �suedfor/on the she?
' �~� ��� �
NO �� D�7K�W �� YES ��
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO k D DON7KNOW 0 YES
IF YES: enter Book Pag and/or Dooument#
�� ��
B. Does the site contain a brook, body of water orwetlands? NO «�� DON'T VV x~_*�N� YES �~�
IF YES, has permit been orneed to be obtained from the Conservation Commission?
~
Needs to be obtained »�� Obtained /~� Date Issued:
v_� ��' ' �
C. Do any signs exist onthe property? YES 0 NO
IF YES, describe size, type and location:
D. Ar_e there any proposed changes to or additions of signs intended for the property? YES NO
IF YES, describe size, type and location:
E Will the construction activity disturb grading excavation,m filling)over 1acre or isdpart ofa common plan
that will disturb over 1acre? YES K � NO
`~�
|F YES,then a Northampton Storm Water Management Permit from the DPW is required.
`
<-
City of Northampton
}ti Building Department
l ' 212 Main Street
Room 100
^T+5 Nt; hampton; MA 01060
tl r phone"413- 87-1240 Fax 413-587-1272
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APPLICATION TO ON `StkUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
This section to be completed by office
1.1 Property Address: `
Vlap Lot Umt
r/9�
Tone,,
Overlay Drstrcf
Fm sL District M w.•.> cBpistnct
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGE, NT.
2.1 Owner of Record:
Name(Print) Current Mailing Address:,
L
Telephone
Signature
2.2 Authorized Agent:
y<i X13 F19 01
Name(Print) Current Mailing Address:
nature Telephone
SEGTION 3-ESTIMATED CONSTRUCTIONCOSTS
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 Permit Fee
4. Mechanical(HVAC)
5.Fire Protection
6. Total=(1 +2+3+4+5) Check Number
This"Section For O.fficial Use Only
Date
Building Permit;Number Issued_
Signature: -
Building Comm issionedlnspector of Buildings Date
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54 FAIR ST-FAIRGROUNDS BP-2005-0879
GIS#: COMMONWEALTH OF MASSACHUSETTS
MM:Block: 25C-251 CITY OF NORTHAMPTON
Lot:-001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2005-0879
Project# JS-2005-1213
Est. Cost: $2500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Joseph Jasinski 100616
Lot Size(sq. ft.): 871200.00 Owner: HAMPSHIRE FRANKLIN&HAMPDEN
Zoning:URA Applicant: Joseph Jasinski
AT. 54 FAIR ST - FAIRGROUNDS
Applicant Address: Phone: Insurance:
43 FAIR ST (413) 584-0307
NORTHAMPTON MAO 1060 ISSUED ON:3122105 0:00:00
TO PERFORM THE FOLLOWING WORK:INSTALL METAL ROOF OVER EXISTING
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 Sienature:
FeeType• Date Paid: Amount:
Building 3/22/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo