03-017 (4) ¢�tSA.MA
O O
DEPARTMENT OF BUILDIjG INSPECTIONS /Z
INSPECTOR 212 Main Sweet • Munic;ipd Building 'a�
Nortllunpton, 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 supe_-.,,.or. 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 occupanev
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
ade �y
C_ , understand the above.
r
(Home owne /resident's signature requesting exemption)
I will call to schedule all required building inspections necessary for the building permit
issued to me.
Date > ' 6 ,?
Address of work
location 5 s %/,v 3 H e / /?/
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washinaton Street
Boston,MA 02111
www.mass.gov/dig
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone.#:
F 2.0 you an employer?Check the appropriate box: Type of project(required):
I am a employer with 4. [] I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction
I am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling
ship and have no employees These sub-contractors have 1 g. Demolition
working for me in any capacity. employees and have workers'
insurance. 9. ❑Building addition
[No workers' comp.insurance comp.
required.] 5. 0 We are a corporation and its 10.F-1 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
-'xriy app(icanT a c ec ox must a o out a section a ow s ovv�ng eir wor compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investizations of the DIA for insurance coverage verification.
I hereby certify under the pains-and penalties of perjury that the information provided above is true and correct
i_nature:
Phone#:
Lonly. Do not write in this area, to be completed by city or town offrciaL
n: PermibZicense hority(circle one):
Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone#:
SECTION 8-CONSTRUCTION,SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
9 'Retlistere i liome_Imaroveineni`Corrtractor• ,,.';u - . y, ,_ . . Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION INSURANCE.AFFIDAVIT(M.GL.c.1`52,§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...... ❑
l .'-:Hoinr Qnergrpaa
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 and Local Zoning Laws and State of Massachusetts General Laws Annotated.
Homeowner Signature—44"// tt ,
_ r
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors E3
Accessory Bldg. Demolition ❑ New Signs [0] Decks [[] Siding ] Other[O]
Brief Descri ion of Proposed / T ] l x
Work: d
Alteration of existing bedroom Yes No �YAg new bedroom Yes No
—�L Attached Narrative Renovating unfinished basement Yes o
Plans Attached Roll -Sheet
saw i. Nernrhotlse-6 "a or-ac[dltion-to ex stincu-, sii co pietemfheyfo[Covi iriEu:
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 o. s cons ru ion wi i 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-TQ BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR`APPLIES FOR BUILDING PERMIT
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 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 the pains and penalties of perjury.
/[rck.4 y4 .
Print Name
Signature of Owner/Agent Date ,–O
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Z)n1ng
This column to be tilled in by
Buildin.-Department
Lot Size
Frontage
Setbacks Front
Side R-
Rear
Building Height
Bldg,Square Footage %
Open Space Footage %
#of Parking Spaces
(volume&Location)
A Has a SOecial Perm t/Varianco/Findi ng ever been issued for/on the site?
IF YES, date issued::
'--'----
IF YES: Was the permit recorded at the Registry of Deeds?
NO [ } DON7KNOW 0 YES
IF YES: enter Book Page and/or Document#i
�� ��
B. Does the site contain o brook, body uf water orwet|an�? NO ��/ DON7KNOVV �~/ YES �~�
IF YES, has o permit been or need to be obtained from the Conservation Commission?
Needs tobe obtained x~-\ Obtained �~� Date Issued:
v�� v~� ' �
C. Do any signs exist on the property? YES 0 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: |
E. Will the construction activity disturb grading vation,or filling)over 1acre or is it part ofacommon plan
that will disturb over 1acre? YES ���) NO �8
|F YES,then a Northampton Storm Water Management Permit from the IDPVYis required.
Mepartmefi t etse one "'
City of Northampton Status o1 Penr "
Byilding Department CurEx t=&r wa T a
�n (� 212 Main Street 7
L i C 1J lS SewerSept►cAuaEtabrlrt
Room 100 Iar[IdkellAvatlabtltl}
TM Northampton, MA 01060 T�rraSets of StritcturalTpfans_
AUG 2 7k
EMT
413587-1240 Fax 413-587-1272 PloflSEfe flans �, =
`
Othec$peclfy
L_.ARPT,4G1N$TO STIR T,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
Lit �1� (?
SITE INFORMATION ;
r1-1 7;Proper�tyAddress: This sectidrrto-be'comptetedb, ,offi ce°=
• 1414 / Zarte OverlaDrstdcf
r� - -
E>it�St Distrrct C81)istrrcf
SECTION Z-PROPERT('OWNERSHIPIAUTHORIZEDrAGENT
2.1 Owner of Record:
Nab�PGtb�d ��� A S 5-kf � 2�
Current Mailing Address:
-____( Telepho
Signature -7 5
S
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
FMechanica1,,(HVAC) Estimated Cost(Dollars)to be Official Use Only
com leted b permit applicant
1 (a}Building Permit Fee
U (b)Estimated Total Cost_of
Construction:.from 6
Building,Permit Fee
al(HVAC)
tion
6_ Total= 1 +2+3+4+5 Q
( ) Check Number
This Section For Official Use Only
Building permit Number.. Date
Issued:
Signature:
Building Commissioner/Inspector of Buildings- Date
I ,
File#BP-2008-0200
APPLICANT/CONTACT PERSON KORZA RICHARD R&JOAN G
ADDRESS/PHONE 35 LINSEED RD WEST HATFIELD (413)247-5445 Q
PROPERTY LOCATION 35 LINSEED RD
MAP 03 PARCEL 017 001 ZONE RR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out Qq 09.
Fee Paid
Ty_peof Construction: REPLACE BARN SIDING&PIERS
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
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
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.
BP-2008-0200
GIs#: COMMONWEALTH OF MASSACHUSETTS
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-2008-0200
Project# JS-2008-000301
Est. Cost: $6000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sq. ft.): 628570.80 Owner: KORZA RICHARD R&JOAN G
Zoning: RR Applicant: KORZA RICHARD R & JOAN G
AT. 35 LINSEED RD
Applicant Address: Phone: Insurance:
35 LINSEED RD (413) 247-5445 O
WEST HATFIELDMA01088 ISSUED ON:812912007 0:00:00
TO PERFORM THE FOLLOWING WORK.REPLACE BARN SIDING & PIERS
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 8/29/2007 0:00:00 $50.002074
212 Main Street,Phone(413)587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo