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DEPARTMENT OF BUILDIj\'G 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 78OCMR 108.3.4 to
act as his/her construction sup sor. T he state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two famity--_
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 hour) 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
ma e ---�
I understand the above.
( o e 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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'el c:s sat ctinrctta' -
.O DEPARTMENT OF DUILDD\10 INSPECTiol:s - -
212 Main Strect Municipal Building
Northampton, Mass. 01060
WOR-r R'S CO3MTENSATION MSURANCE AI'I'D��i.�TIT'
(li ccu�•xJpertni tttx)
vlith a prmi cipal place of businesslresidence at: — -
— (phone.')
(st1-�t/cirY/ �trrap)
do hereby certify, under thc.pains and penalties of penury, -that
( ) I a rn an employer providing die following'wori:cr's comocnsa�on cove��c for im
etnplovecs working on diis job:
oanu---n=Cocn=v) (Potic-,),,t✓-airr) -- (=:-pirz or,D2j--)
O I am a sole proprietor, general contractor or homeowner(c cie one) aid have hired
the coon-actors listed below who have the worker's comoen_t2Uon pc!icies:
0"tt1ID: Of Contmcior) (Ill-uranc„ CoIAD1r1)•/oUCi D.Itc)
- (NOMC of COUG-2 Tof) (Lristrzn Z ComoaawPolk-i, `um-r) (EaDit lion Date)
(Name of Conuacto,) (Lnsurancr Companyf%Uq- Numb u) (Espindon Datc)
(Namc of Contractor) a=urancc Comrzuy/PoUcy Numbs) (Expiation Datc).
(sa3,�:d�itiocsl�cc if acct �•to incvci iaf«m.;oa pcta,LZ aj:to su
O I am a sole proprietor and have no one working for me.
I am.a home owner performing all the work myself.
NOTE:plea be ew-2rc thz:..-t. le bcmco,m w{�o aiptaY pc-.-o=to cU r-.;.-r•, cam.-.:c oo a rc,•--t.it Wont oz a d..r11 ne of
aot mote th--.n t-w=Ii'tj in u'aieh the bocnoo-oc roido oc cc the Qouz d3 zppuxi a:=tlxeu i c we C=>=ty oec,:d---chi to be
r=xploy=:uzy—'the c -p,--•-,;oo A,=(GL`!52,=1(5)),�- iaboo by a bomcoays fc a lies_or pc-mit ray CN4( ec 0-
IcSA O-M-of e.n exployx under d, Woke.Coo=p m ion Act
I undcci�yd tba a oopy or tbi.- tL c o,y be rot xardea co the Dcgo„mm¢of In Paz scl noad.%'C wM_ur t+�—roc Lb_
covc�"cif ctioa,end tttu Uum to u rc tcollm md--scaJoa 25A of MOL 151 as lid to the impositioa of airman!pc=-W=
coax:.mg of a sDc crup to S 1}oo.0o arzior of up to ooc yr_:ind civi pcuPua in db form of n Slop Work Ord--and a
fi=o(S 100.00.d_y tgxiast tnc
Foc dc�u.c only -
`•' PCT7Mit Nu bcr
Lot i '
rr of Lic=isccfPcrrruLtct -fie
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SECTION 8-CONSTRUCTION SERVICES r
8.1 Licensed Construction Supervisor. Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9`Re `ster"eil°Efiome_Imptoveirecit.CoitraEfor Not Applicable ❑
Company Name Registration Num a--��---- - -
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-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 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 cal omn Law tat f Massachusetts General Laws Annotated.
Homeowner Signature
f
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SECTION-5-DESCRIPTION OF PROPOSED WORK Icheck all applicable)
New House F_� Addition ❑:, Replacemen Windows Alterations) Roofing
Or Doors K_
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [p Siding(o] Other[O]
Brief Descripti n�f Proposed
Work: LAD. u(� �(� � G KJC�( '� c L� `�4� s ! k�iJC Jzc
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes ---"No
Plans Attached Roll -Sheet
sa �€New-house end ciradd itin..s4 e^rfs.sot orerizig�"
:
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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.
I. Septic Tank City Sewer Private well City water Supply
SECTION 7a-!OWNER AUTHORIZATION,-TO BE COMPLETED WHEN
OWNERS AGENT OR'CONTRACTOR APPLIES 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
as Owner/Authorized
Agent here 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 Narp
ignat a of Owri r/Agent Date
~ �
Section 4. ZONING All Informatibn 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 L
Setbacks Front
Rear
Building Height
Bldg.Square Footage
Open Space Footage %
(Lot area minus bldg&paved
of Parking Spaces
L(volume I&Location)
^
A. Has a Special Perm it/Vahunca/Findi ng ever been issued for/on the site?
N . v-\ DON'T KNOW YES 0 �
IF YES, date issued::
IF YES: Was the permit recorded at the Registry of Deeds?
NO K } DON'T KNOW 04P YES
IF YES: enter Book Page, and/or Document#
B. Does the site contain u brook, body uf water orwetlands? NO �Dk DON7KNDV � YES 0
IF YES, has permit been ur need tu ba obtained from the Conservation Commission?
'
Needs to be obtained »~� Obtained x°~\ Date Issued:
v�� v�� ' '
��
C. Do any signs exist on the pnoper�? 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 0 NO ^�u
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading uavahnn.or@|ing)over 1 acre oriodpo�ofa common plan
that wiUdi�u,bover 1acre? YES K � NO K ~
`_^ � `_~
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
s
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y orWampton Scat of P rrn tr m
' 1:+116 Department ve Perms
212 ain Street $ewe�eitt
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Northa pto AMA 01060 T'� e�s fStr to a!Pta rs �'�
phone 413-58124 Fax 413-587-1272 plid ltePtans "
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 --SITE INFORMATION
1.1 Property Address: This,section to be completed by office ,
Z 1-✓C✓�y,�Q� � - Map Lot Unit
_ -0
Zone Overlay District-
Elm SE D�str►ct CB District
SECTION 2-PROPERTYOWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
�SL,ff(,�� �+ � v�� - 7 Wit �
Name ri ) ! Current Mailing Address:
Telephone 3 s,�_�' �F 6
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 ,j �� (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
6' Construction from 6
3. Plumbing (` c9 C.�' Building;Permit Fee
T G'-
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) / ` p,90 Check Number 6
This Section For Official Use Only
Date'
Building;Permit Number.' Issued:
Signature:
i
Building Commissioner/Inspector of Buildings Date
File#BP-2005-0711
APPLICANT/CONTACT PERSON SIMURDA STEPHEN J
ADDRESS/PHONE 972 RYAN RD FLORENCE (413)585-8496 Q
PROPERTY LOCATION 12 WARREN ST
MAP 17C PARCEL 007 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Buildiniz Permit Filled out
Fee Paid
Typeof Construction: ADD 2ND FLR BATH IN EXISTING, SHEETROCK KITCHEN,INSULATE&UPDATE
ELECTRIC
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
INF9164ATION 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
2cV S
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.
12 WARREN ST BP-2005-0711
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-007 CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildiinq DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category Non structural interior renovations BUILDING PERMIT
Permit# BP-2005-0711
Project# 35-2005-0977
Est. Cost: $17000.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa. ft.): 6011.28 Owner: SIMURDA STEPHEN J
Zoning.URB Applicant: SIMURDA STEPHEN 3
AT. 12 WARREN ST
Applicant Address: Phone: Insurance:
972 RYAN RD (413) 585-8496 ()
FLORENCEMA01062 ISSUED ON.1111105 0:00:00
TO PERFORM THE FOLLOWING WORK.-ADD 2ND FLR BATH IN EXISTING, SHEETROCK
KITCHEN, INSULATE & UPDATE ELECTRIC
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 1/11/05 0:00:00 268 $65.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo