25C-248 o4�KAMP�O
g� ti$ Crier of Xart4ainptan L _
1�1833ACh Ii3ttt3 -
DEPARTMENT OF BUILDING INSPECTIONS
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 sups: , 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 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
---
(1-zft�T c1f �7z tlj�tltl}�fntt -
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�r DEPARTMENT 017 rUILDP�G Ir SPECT�10�qs �
212 Main Street ' AfunicipILI I3uilding
Northampton, Mass. 01060
WORTCER'S COTNITENSA'MN I7tSURANCE ArFMANIT
1,
v"Ith a principal place, of busiressJresidenc_
C{0 I1CrCJ}' CCrC1I}', :' ;I- 1_11C 1)2iThs ::ii7 1)Cila 121'2`.; of pc;I�l1I; 1111!:.
( I ?m an employer provldln- the i011ov;Mn '.':OI :CI S COtI9DC!]SaUOI) GOVCI'2��C f0- T11)
employees working on this jobs
(IIlS`.I12nG Conk }) c!c:NumErr) ---- �ra.F•ir,:ion Date)
( j I am a sole proprietor, -ent-ra± con roc cr cD-, honT-O'NDC- (M CIC one i and t:a'.-e hired
the contractors listet, beio','v-�v)o it c ill?
('Name. of Contractor) (Ins ace Corn:) Policy Numtxr) --- a:r,c�: Datc)-
't .
(Name of Contractor) -- t7ns r:c° Com tr/PGtICi �1iS]G r) --TL�:�iralion Dale
(2�'ame of Contractor) In ., ;c. �u.n t. r___. - `✓
- (Name of Contractor) — (Iasi:ranc� Color };Polier Numb,-*) Date)
nil
1, 1 `211 2. �O1C 1?I U1)I1CtC?i <'.iIQ havC no ol"c, Ui"1�iiie' t0; it?C-
2121 11/01110
NO ITi:please be nti,�c L'sr'.1 ile hr rco nr: ,,o cal.. Cr:c;;,11"
not uxre th:n duce uui��ir.tti:ic�t•max!:-r.:ti�-rair-rc::,:;�a cc
ca'.ployv�u_zicr t}r tvc;}:a'c cc i a,;a(OLIS2 c!(511,al:, ._a:icr by hcmcoa�—r for r lice c ct
legal rtatun of rn c I;)loyx under tL•c Workce-C-C mro--Ikn!.cL -
I underhand thst a cony of(}u ctatc.-i-s�n:.ay to Io[x•vcio;l tot;o(YSxirL�,ccL of Ird ,%riJ- M6Gm:�CiLcb of i.:=�.�c�-'T"4 for tix
covera&C vCr-�C:Iio0 and Uut f-ilure to:•z:,r ro«�„ur:3:r:cCtio^25A cf MG1,152 can Ic-d to tlx-imposition
romuting of a fur of up to S I.SCK�-QO n;,'n i^:pr: r.z_;
of tip to rr.:}- a:-.I c vil pcnz26o in f c f n n of a S!r;
fm o(S100-00 a diy i -in:t m:,
ru<
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SCT�ON 8 CO:NSTRU,CTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
. on Not Applicable ❑Re to e ern em
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 1N0_RKERS' COMPENSATION INSURANCE,AFFIDAVIT(McG:L..c. 152, § 25G(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...... ❑
r
Elm
-
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, e and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature
i
SECT�iO DES RIPTi1.ON OF3PROPOSED VY0RK check atl;a n lacable
f � ..
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ j Decks [ ] Siding [ ] Other [ ]
Brief Description of Proposed Work: b l CU,'/1 dD / r2 Q7V
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative❑ Renovating unfinished basement Yes No
Plans Attached Roll D- Sheet 0
6a fie o se"""a d or dit-ion to ezisting.h u°s=ing com— a he:�n�ol1, in-:
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 Nc
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulati.ons? Yes No
I. Septic Tank City Sewer Private well City water Supply
SECfI[ON Z M OWNEf AUTFIORIZATION TO BE COMPLETED WHEN
OWNERS"kGENiDR CONTRACTOR APPLIES FOR BUILDING PER
I. as Owner of the subject property
hereby authorize to acs or
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
1, 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 yqer the pains pnd penalties of perjury.
d J —
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 ize
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:
a
t
o' Northampton
' I i' ' Department
Y 2004 I &A ain Street
R om 100
Northam ton, MA 01060
4phb X587-1 40 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
4 This section to be completed 5y oflFce
1.1 Property Address: °
����Y���-���►'� f")'1�{ �l d�C� Zo66X111* �� " ' �r►eriay Oa�ct
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,ElIn1�.DISt17Ct � n � ,C$D"rstrict
SECTION-2 PROPERTY OWNERSHIP/AUTHORIZED'AGENT
2.1 Owner of Reco ��jj
1G1 ✓� C /ACC' ��cc J �� CJ
N (Print) Current M fling
L--�- Telephone
Signature
2.2 Authorized Agent:
e(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 ri_ (a)'Building Permit Fee
2. Electrical (b) Estimated.Total Cost of
Construction from" 6
3. Plumbing Building Permit Fee
4. Mechanical (NVAC)
5. Fire Protection
6. Total = (1 + 2+ 3+4+ 5) -Chef Number :
This Section For Official Use Ord
Building Permit Number: Date Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2004-1143
APPLICANT/CONTACT PERSON NOWAK ADRIAN&PATRICIA
ADDRESS/PHONE 37 OLD FERRY RD NORTHAMPTON (413)587-3959 Q
PROPERTY LOCATION 37 OLD FERRY RD
MAP 25C PARCEL 248 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 17Y llak9 Z/
Typeof Construction: REPLACE ATTIC VENT W/WINDOW
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 FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO RMATION 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 on
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.
37 OLD FERRY RD BP-2004-1143
GIS#: COMMON' iLTH OF MASSACHUSETTS
Map:Block:25C-248 C OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTli lTH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS 7 -iE GUARANTY FUND (MGL c.142A)
Category:windows replaced B1 LDING PERMIT
Permit# BP-2004-1143
Project# IS-2004-0954
Est.Cost: $300.00
Fee:$50.00 PERMISSION IS I ':BY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contrz _
Lot Size(sq.ft.): 10018.80 Owner. NOWAK ADRIF \.TRICIA
Zoning.URA Applicant: NOWAK AD A PATRICIA
AT: 37 OLD FERRY RI
Applicant Address: e: Insurance:
37 OLD FERRY RD S) 587-3959 O
NORTHAMPTON MAO 1060 ISSUED ON.5121104 0- !^
TO PERFORM THE FOLLOWING WORK.-R' ATTIC VENT W/WINDOW
POST THIS CARD SO IT IS VISIBLE FROM THE S ,r
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings-
Rough: Rough: House# Foundation:
Driveway
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY C ORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy ure:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 5/21/04 0:00:0" 147 $50.00
212 Main Street,Phone(413)587 "�,Fax: (413)587-1272
Building Commissioner- !iony Patillo