25C-253 4�tiAMp�
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�., DEPARTMENT OF BUILDING INSPECTIONS
INSPECTOR '212 Main Street • Municipal Building '
North,,unpton,MA 01060 ,M 5
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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 super�'l 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 fami
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 backfrll),
sonotube holes (before pour), a rouzh 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.
(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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DEPARTMEI T OP BUILDf7\C INSPPCr101.'s
212 Main Strect Municipal Building
Northampton, Mass. 010GO
WORICER'S C0,1YIPENSA.TION LEISURACE AI, , AVI-I"
I
(li perm�ttcc)
%IrI h a pnncipal place of business/residencc at: - -
hone!
(sIIr...t/ci t`Y/slaicr�p)
do hereby certify, under the pains azd penalties of pc9ury., ihal
( ) I am an employer providing file followine'workc�s comocnsabo, coverage
for my
ciuplovices Nvoridng on Oils job:
i (Lmur n= Com=rv) (Pcbc-. ?:u_-ter) (L-:-pirrion DaLt)
I am a sole proprietor, general contractor or homeowner(c cie one) and have hired
e cooiractors listed below wbo have the fb[lo%viog workers col oen_adon policies:
(NL amc Oi C0 t^cior) Gn ur.7ncc Coinpa+'yiflobci NuIIL<I) (-Expi juon Data)
(Name of Coo-actor) (Iris-- ncc Comoan}vPo!im, Nunc_r) (Ex..6on Date)
I
(Name of Connaao;) (Insw-anec Compan y/Polio- Number) (Expirlion Date)
(Name of Coamcior) (Insurancc Company/PoUcy Numb:.r) (Expirtion Date).
(ntx.a[h to atdud_inform.Zioc pc1a1ning to.0 coal--,=:3) -
I
x I am a sole pr-opnetor and have no one worldog for me. �ekerE�l '�dl1P I am,a home owner performing all the work myself.
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? NOTE:pl--=be noryrt LhL1N jijC b0cDC13VTo=-bo c=P1ay pcn,=Lo do r r-uir work on L d•--LL--Z of
1 aac most th=t'r==As is uiycb Lb,bomb -z=rcp�dQ IX oc tb1 F muV L?pjr cop =tb=C-o LT ooc L`=>- -Uy Q crid-of to be
-3*0y--a the wui ets cc Pc=:- ca Ac:(GLJI52-n 1(5)x,=pplianoo by a bomcoaac fv c G=-�:or pc-mit zy Ehc
109a1 n om•...of nn es7loyx under dao W.+-e,
ComprmaLioa Ad
ICI 1 uodcvLz d dLd a Dopy orthi.aztcmmt may be f--.-,ded to tbo popa.ca,mt of Iadtiiuic!AoodaII&OT,-of L.—foe th.
aovcrL&c vrs c=ioo and 0=1 Ldtac to soaut tovorssc un&r socdoa 23A of MOL 152 m lad to the imp=idoo of aimi=d pcanlLia
C—LCiag of a S=of up to S 1500.00&r0f r imp i of up to ooc yr=Lod a-,il posif'ua io the form of a Stop Work Ordc and■
C=0(5100.00 1 day.p,iait me
For dcp.^ fit u.c Drily
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Pcrmtt Numbar
Lot
Sir;,;co of U.C=ISwjperrfULLCC c -- J
SECTION 8-CONSTRUCTION SERVICES r
8.1 Licensed Constr ction Su ervi r: Not Applicable 0
s —
Name of License Holder: C � � �� 4.3vv 0
License Number
41 /06/1
Address Expiration Date
Sign tore one
$area sere" orneriars�reme racto Not Applicable ❑
Company Name Registration Num er -
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE"AFFIDANIT`(M:G:L.c.152,"9125G(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-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
f
Y"
SECTION 5-DESCRIPTION OF.PROPOSED WORK(check,all-apalicabfel
New House [] Addition Replacement Windows Alteration(s) ❑ Roofing
Or Doors D
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[C:3] Other[d]
Brief Description of Proposed Xi , �r AY elf
Work: f �r!� !sc 5
- _ _ __--.. . _
Alteration of existing bedroom Yes No Adding new bedroom Yes No All
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa
. e hot�sean. r d>#�o a x>IStlnc iio 'slng;comniefe the n tow.>ng:
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
i
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 BECOMPLETED WHEN.
OWNERS AGENT:ORCONTRACTOR'APPLIESFOR BUILDING:PERMIT~
I, At b et //'E�TI 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
.' as Own uth
hereby declare tha the tatement nd information the foregoing application are true and accurate,to the best o my knowledge
,AgSt Cand'belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of er/Age t Date
d
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
1
Lot Size
Frontage 1
Setbacks Front
Side L R= R:
Rear
Building Height -- --
Bldg. Square Footage % l
Open Space Footage %
(Lot area minus bldg&paved c ?
parking)
#of Parking Spaces —
Fill: ! l
(volume B&Location
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO 0 DONT KNOW 0 YES 0
IF YES, date issued: �
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DON-r KNOW 0 YES 0
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO DONT KNOW 0 YES 0
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 Date Issued: s`
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C. Do any signs exist on the property? YES 0 NO 0
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:
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 0 , NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
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City of No#ampton
Building Department
212 Main Street
Room 100 t
Northampton; MA 01060
phone 413-587-1240 Fax 413-587-1272 tugs►
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE.iNFOR_MATION
1.1 Property Address: This sectron'to be completed by office
;Lot Unrf
.t�(e f
Zone Overla�r;Drstr�cf
�Elrit 6t.,Drsfrrct � 'N� ;���a°� � CB,Drstnct
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
2.1 Owner of Record:
fiAl 3l i c5'77
Name(Print) Current Mailing Address: r
XTelephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATEb-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 Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) --C V CheckNumber etx L19 d
ThisSection For Official'Use Only
Date':
Building`Permit Number: Issued:
Signature: '
i
Building Commissioner/Inspector of Buildings Date
Alan R Shumway Proposal
625 East Pleasant St
Amherst, MA 01002 DATE Proposal #
(413) 549-4658 4/14/2008 531
NAME /ADDRESS
Albina Pirog
31 Fair St
Northampton, Ma. 01060
TERMS LOCATION
On completion same
DESCRIPTION TOTAL
Scope of work: Provide all labor, materials and equipment to install new roofing
on back dormer and front porch.
Install new .032 alumn. drips
Install modified bitumen SBS granulated rolled roofing
Price includes permit to city of Northampton
Check flashing at chimney, slates
Total: 1,730.00
All materials are guaranteed as specified and installed as per TOTAL
industry standards. $1,730.00
CONTRACTOR SIGNATURE
OWNER SIGNATURE
File#BP-2008-0934
APPLICANT/CONTACT PERSON SHUMWAY ROOFING
ADDRESS/PHONE 625 EAST PLEASANT ST AMHERST (413) 549-9658
PROPERTY LOCATION 31 FAIR ST
MAP 25C PARCEL 253 001 ZONE URA
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
ke Paid
Bu' Ing Permit Filled out
_ ee Paid
Typeof Construction: Reroof back dormer and front porch
New Construction
Non Structural interior renovations
Addition to Existine
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
INFORMATION 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 ,Permit DPW Storm Water Management
Demolition Delay
/Z3LO
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.
t3,, *W ,W BP-2008-0934
GiS#: COMMONWEALTH OF MASSACHUSETTS
Age m. w 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-2008-0934
Project# JS-2008-001397
Est. Cost: $1730.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: SHUMWAY ROOFING
Lot Size(sq. ft.): 30099.96 Owner: PIROG FREDERICK A&FRANK J
Zoning: URA Applicant: SHUMWAY ROOFING
AT. 31 FAIR ST
Applicant Address: Phone: Insurance:
625 EAST PLEASANT ST (413) 549-9658
AMHERSTMA01002 ISSUED ON:412312008 0:00:00
TO PERFORM THE FOLLOWING WORK:Reroof back dormer and 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: Date Paid: Amount:
Building 4/23/2008 0:00:00 $25.004904
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo