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DEPARTMENT OF BUILDING INSPECTIONS /
INSPECTOR 212 Main Street • Municipal Building '>o
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 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 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
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w DEPARTMEIrT OP BUILDP\10 INSPeCTt01.'S
212 Train Street Nfunicipal Building
Northampton, Mass. 01060
V,'O R1Q.R'S CO ATP EN S A'n 0 N Lit S URAN CE A FFM A VIT
(Iiccns.^:lpermitt'cc) - - ---
f v.9th a prmcipaJ place of business/residencc at:
i
``j -Z-✓z`� f3f��9`� l�•�'I�'��1{�I j°�A DrG��C, -(pnone�') _�S`/-5�f1 ��
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(sum-tic�rl/st�lc�II p)
i do hereby certify under thc.p?-ins end penalties of perjury., hzt
i
( ) I am an employer providing the folJowine v,,orher S COMDU)S2J0, coverage (or my
elnplovecs woridng on this job:
(Las=aD= Comp-: ) (Policy N'u-mbcr) -- (E_:•pirztion Dzar)
( ) I am a sole proprietor, general COou-acaor or homeowner (Ci cie or2c) 2Dd have hired
the coouactors listed below who h2ve the folio%wing worker's policies:
(1,4amc Oi Conl^ctor) (In urancc Coinpa;I)-Ph Date)
-- (Na c of Coonmor) (Irns =Ca ComanyRolic- Numt ---r) (txp) ,uion Date)
(T'ame of Con>raetor) (Insurance Compan)/Polie) N:u>?bcr) (Expi.rtioo Date)
I
(Name of Contractor) (Insurance Compaay/Policy Numbs) (Etipiradoa Datc) .
(&rich zddi--�oc31 c'ucc.ilnccciry to jrj tud=inform,Ecpczvuaias to art ate•-_c_.on) a
( ) I am a sole proprietor and have no one worJd.ng for me.
( j I am..a home owDer per-formi-ug all the 1vork myself.
NOTE:plesc be ewzr•e tt+r•.. Je beme�w,vm u,,o ec=play pcs.Crm to do c�—,Lc c repay•oric oo or
\.. apt mocc tIL Lb-c-rmtu is we.Ch the b=oowoC rt=ida«oe the p-ouac,zppurtca--r_�tbeen c.-c oo(C=�.•r ty oc- id-cd to be
stplo)—11L C the .«icy 0=p—.,:m Aa(GLI52s31(5)) =4*Uc 6crc try a bomcoava rta:bc==�.or po=iz—Y c�idm t�c
of na—ploy.,r under dzo Worti, ,Coc*--Lion Aax
[uadrn-_yad dL�2>wpy or Chia=t®mx o y be foc•+rcv�•Sa.d w tbo pcpn�tmers of In�at�i.J Accid—&OM—of trrur•ooa roc tha
cove G-c vrrif—ioc rind du L-iltac to sccstcc tovczasc undo sociioa 23A of MGL 152 na lad tp the i p 00 of citninsl Prn-lvo
com:smg of a ripe of up to S l X00.00 anN-it cwamo orup to 0p yry Lzd 6,U pcox_,-io io dS focm of n Stop Work Ord and a
ft=0(S100-00 a dzy aVLinA me
For dcp.rtzx��1 u.c onty .
PcTmtl NtlIDbcJ Lot i d.
Si�-tttut of Lic=Lsa-JPcrmiucc _
A �
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9:Re`aiste�ed..Home lrnprovenaer}fiConfractor„ r Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M:GL.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-owna-parcel.ofland 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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House F-� Addition [7 Replacement Windows Alterations) Roofing
Or Doors
Accessory Bldg. ❑ Demolition ❑ New Signs [[3] Decks [M Siding [C]] Other[[3]
Brief Description of Proposed _
Work:_ FE'V(qf 10aCif JN� WSTAU, RkfJ-Aq A N 't_ W14uCOWJ
Alteration of existing bedroom Yes ;./ No Adding new bedroom Yes _�i_No
Attached Narrative Renovating unfinished basement Yes _1e!!-'No
Plans Attached Roll -Sheet
sa ffNew house.nd radd tlon to eieis`tln�g hi u Isis compfe#e`f eil i
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?
I 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.
I. Septic Tank City Sewer Private well City water Supply
-SECT IOW7a==-OWNER,AUTHOFtIZATION--7"O BE`EOMPI=ETED.::WF 1EN-
OWNERS':AGENTOR"CONTR,ACTOR`APPL°!ES 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.
Signature of Owner Date
s�Owner
uthorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the-BMf-of my knowledge
and belief.
Signed and r the pains and penalties of perjury.
Print Name
Signature of Owner/Agent Date
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Section 4. ZONING All Information 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#of Parking Spaces
ji
A. Has a 3pooe/ Perm it/Vorunoe/F ever been bsuedfor/on the site?
� l
NO �~�� DONTKNO/ VV ^�� v�� ~~�
IF YES, date issued:
IF YES: Was the permit recorded at the Registry nfDoods?
NO v~`� OON'| KNOW YES\��
IF YES: enter Book Pagel and/or Document�
B. Does the site contain abrook, body of water orwetlands? NO v�\ DON7KNOVV YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained �~� Obtained /-� Date Issued:
\,� �_/ ' �
C. Du any signs exist un the property? YES [ J wu
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO
IF YES, describe size, type and location:
E Will the construction activity disturb( hng.grading, excavation,or filling)over 1 acre orisit part nfa common plan
that will disturb over 1 acre? YES ��{ ) NO
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
' Deparfinent.use Daly -.� ,�
City of Northampton 5tatusp Perrnl "
Building Department -1611cls�tDvew - e 5 � $,,
212 Main Street Skid erSe' arlab I �� �
Room 100 el�Avaita6rla '
Northampton, MA 01060v �� ruaata � �
phone 413-587-1240 Fax 413-587-1272
_ 6 •r x.�. arr-a;-�
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO-FAMILY DWELLING
SECTION:1:-SITE INFORMATION
This section to be completed byffice,
1.1 Property Address:
3
Map l-Dt t Unit
A/'J9 '�'/&Ve Zoxie f Ouerla�llistrrct.
rz
EIm St Distract s CBDistnct
SECTION.2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1/�/Owjne�rjof Record: /
Name(Print) Current M ilin Ad Tress:
� I �! Jp� yC.�
k1e�.rl/1 Telephone
Signature
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)BuildingPermit Fee
2. Electrical (b)Estimate&Total Cost of
Construction;.from,6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total =(1 +2+3+4+5) (r e'a t
� ,Ud Check Number -
Th'is SectiomFor Official Use Onl
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
File#BP-2007-0497
APPLICANT/CONTACT PERSON NOWAK MATTHEW A
ADDRESS/PHONE NORTHAMPTON
PROPERTY LOCATION 259 BRIDGE ST
MAP 25C PARCEL 246 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Fi ed out
Fee Paid o-
Typeof Construction: Reroof and replacement windows
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 WMATION 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 Commission
e�;� W_,� M/ 6 �
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.
259 BRIDGE ST BP-2007-0497
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 25C-246 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-2007-0497
Project# JS-2007-000723
Est. Cost: $6000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: HOME OWNER EXEMPTION
Lot Size(sq. 1): 5793.48 Owner: NOWAK MATTHEW A
Zoning: URB Applicant: NOWAK MATTHEW A
AT. 259 BRIDGE ST
Applicant Address: Phone: Insurance:
NORTHAM PTONMA01 060 ISSUED ON:1013012006 0:00:00
TO PERFORM THE FOLLOWING WORK:Reroof and replacement windows
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 10/30/2006 0:00:00 $25.00157
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo