17A-206 (3) "$ , .Crzfy of 'Nart4amp#an z z
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-, DEPARTMENT OF BUILDD\'G INSPECTIONS
INSPECTOR '212 Main Street • Municipll Building '>a
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Northampton,MA 01060
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 fame -
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 fegulations. 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
7 ade
I, �64 - -- understand the above.
(Home owner/re ent's signature requesting exemption)
I will call to schedul 11 required building inspections necessary for the building permit
issued to me.
Date
Address of work
location
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DEPARTMENT OP BUILDrNG INSPECTIONS -
212 Main Strect Nfunlctpal Building
?Northampton, Ntfacs. 01060
WOJUCCR'S COMTENSATION MSURAA CE AI 1 AVIT
i
(li ccusxJpermi tfcc)
v.�th a principal place of business/resident- at: -
(f hone--)
(sur--Ucit—/starchp)
do hereby certify, under the.pal(]s and penalties of perjury, hai
( ) I am an employer providing the foliowinc,'%vorkcr's comocnsZao, covemge for ln)•
eluplovees worUng on this job:
I
(Ibsumn=Con (Polio: ?:U--Zb--r) -- (r;•pima on Dar)
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O I am a sole proprietor, general conrracor or homeow"Der (ci c;e one) and have hired
the con tors listed below wbo have the foilo,,wing workers coi oen_aijon policies:
(Nainc o; Co`7tMaor) (IRRlrancz CoinowryOi o6c D1tc)
I
i
(Name 01 Coonctor) (his-W anc:. Comoanv/Folic'. Nu.ulcrr) (—Ex r.6on Date)
(Name of Co=o-id,-) (tnsurancz Compan)•/Potic-y N:ssbe.r) (Expirrioo Dalc)
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(Name of Contractor) G=rancc Company[Poliey Numbs) (ExpiFI16oa Dale).
(atz,d emu:ocal �,iracc�.cO•w¢tcuc�imrormi'i00 pcna:ic�nc to au oom---r_o:�)
O I am'a sole proprietor and have no one worL-i-Dg for me-
j I am-a home owner performing all the work myself.
NOTE:plcsc be acvlrC tt,. +1 }c bcmco.vm .)�aaplay P�'som to c5� cs r�oo c rr air,•uric ov.d••c1L: of
i aot mote th:a tl�m tmrr is u}s�the bomootwncr rgido a oo the p-artxS i,purtcarl tbeen�-c ax�-�.r..lty cecrd..-ai to be
cirployc� 'e the wuiUtz -r-•+.c¢A=(GLI52-n 1(S)�=W inboa by a hommaaa f=c lip-a permit ez=y cr+d�x the
ICP1 n,^,•of aM erlloyx wader tbo Wo�lrela Co¢WomaLioa Ad
i
th,a>oopy of tbi.mrcm xrr a y be foci ,ded to tbo Dcq—,—,of Ioda+siiJ Aoad=s&OM—or la.+r+000 rot tb,
novcrq-c vciC alioa acrd O-E L-iliac to sxurc tOvrTy =nd=sot oa 25 A of MOM,151 m I¢d to the ifiOn err ciminsl poa Ilia
ooaLLrixg or a rmc orup to S i}oo.00 arldror 6=;ria0�Orup to ooc yar e.od Civil pm+hia in 6c ram Ora Stop Wort;Ord-- and a
fl=or S 100.00.d_y Lpaist tnc
Fa dam'— u.c only
/ Pcrmn Numbcs
Map=
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i SignaMM of Li rrniucc e
SECTION 8-`CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
Not Applicable ❑
"Lec s ere Home` napropementl;ontracfa �
Company Name Registration Thum e—�-
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...... ❑
t1 �vmerKrm ®l
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,Stat and Local oning Laws and State of Massachusetts General Laws Annotated.
J[omeowner Signature'
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SECTION 5-DESCRIPTION OF-PROPOSED WORK(check all applicable)
New House [❑ Addition ❑ - Replacement Windows Alteration(s) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [M Siding[0] Other[p]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
- Iex ioung ulg:�a bb .f 1ew=IOUSe nd sl
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 AUTHORIZON ATI -TO BE. W
COMPLETED HEN
OWNERS AGENT,OR CONTRACTOR APPLIES FOR BUtLDING: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
i, 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 under t�ains and penalties of perjury. '
Print Na
®c
Signatur of Owner/Agent Date
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Section 4. ZONING All Informatioh 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
i
Lot Size '
Frontage
Setbacks Front !
Side L: R:� L:' R:i
Rear
Building Height -----
Bldg.Square Footage j % �
Open Space Footage %
(Lot area minus bldg&paved
I—�
varkina)
#of Parking Spaces
Fill: f `'
1
(volume,&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 DONT KNOW Q YES t
IF YES: enter Book Page' and/or Document#}
B. Does the site contain a brook, body of water or wetlands? NO 0 DON'T KNOW 0 YES 0
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 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 0
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 r NO 0
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Northampton ;
Building Department
4
212 Main Street
Room 1.00
Northampton; MA 01060
phone 413-587-1240 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 SITE INFORMATION
t 1.1 Property Address: This secUorr toube completed by affce .,
k _ Y
I `�� �{— ilAap Lot rp Unit
t� � ! �(� �e..- �►` Zone
Overlay'i7�stuct
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SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Name(P' Curre t Mailin A dress
I�� 3cf c�3
Telephone
Signature
2.2 Authorized Age
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
Building 6 (a)`Building'Permit-Fee
2. Electrical Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=0 +2+3+4+5) Check Number aJr
This Section ForOfficial'Use Only
Date
Building Permit Number. '.Issued:
Signature: r
k
Building Commissioner/Inspectorof"Buildings Date
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137 NORTH MAPLE ST BP-2005-1224
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17A-206 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1224
Project# JS-2005-1642
Est. Cost: $2000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa. ft.): 23348.16 Owner: JASINSKI CHARLES E&LISA L
Zoning. URB Applicant• JASINSKI CHARLES E & LISA L
AT: 137 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
137 NORTH MAPLE ST () 584-3463 ()
FLORENCEMA01062 ISSUED ON.619105 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE GARAGE ROOF
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 6/9/05 0:00:00 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo