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51 �, DEPARTMENT OF BUILDING 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 780CMR 108.3.4 to
act as iris/her construction sup,Jsor. Th, state defines "l-Ionneowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or t►vo 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 backffll),
sonotube holes (before your), a rough building inspection (before work is
concealed), insulation inspection (if required) and a final buildinz 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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SECTION 8 -'..CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder -
/ License N tuber
Add ess Expiration Date
Si iature Telephone
istered:Home! niorovemen` Co'ntra`ctor Not Applicable El
Con any Name Re ra on Number
Addfess Exp r tion 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...... ❑
1 �
73oin�e ®wnerxempt><on
The current exemption for"homeowners" was extended to include.Owner-occupied Dwellings of one(1) or two(2) farni:ies
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-year period shall not be considered a homeowner.
Such"homeowner"shall submit to the Building Official, on a fort„ ;acceptable to the Building Official, that helshe 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 ap licabfe
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs ] Decks [ ] Siding[ ] Other [ ]
Brief Description of Proposed Work: _-��,-rlf�
Alteration of existing bedroom L_—Yes No Adding new bedroom _ Yes No
Attached Narrative I1 Renovating unfinished basement ------Yes _ No
Plans Attached Roll ❑ - Sheet ❑
6a. If New,.-460se.a'ritl or addition to existing housing, complete the following:
a. Use of building : One Family_ _ Tv,c Fam iv _ - 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. - %lascheck Energy Compliance form attached?
h. Type of construction
Is construction within 100 ft. of wetlands? Yes No Is construction within 100 yr- floodplain Yes _ -__ Nc
j. Depth of basement or cellar floor below finished grade _
k. Will building conform to the Building and Zoning reg!,lations? Yes _ _._ No .
I- Septic Tank City Sewer Private well City water Supply
SECTION 7a-OWNER AUTHORIZATION - TO BE COMPLETED WHEN
OWNEF S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
-- --_ —_ _— _-- -, as Owner of the subject prop ry
hereby authorize - to ac. o�
n,v behalf, in all matters relative to work authoriz + t v th I ,jiidirg 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 m_v
knowledge and belief.
Signed under the pains and penalties of perjury.
Print Name
Signature of Owner/Agent _ Date -- _ -
1
Section 4.
ALL INFORMATION MUST BE COMPLETED, or PERMIT CAN BE
DENIED DUE TO LACK OF INFORMATION
Existing Proposed Required by Zoning
This column to be filled in by
Building Department
Lot Size
Frontage _
Setbacks Front
Side I,: R: L: R:
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces
Fill:
volume&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO DON'T KNOW YES
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO DON'T KNOW _ YES
IF YES: enter Book Page .__ and/or Document ##
B. Does the site contain a brook, body of water or wetlands? NO GON'T KNOW
YES
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 _ NO c�
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
--- � N,k e art en tat se nl
ortharn -tnII Statu s of Permit
_
� ! Curb Cut/Dnvewa �f'ermit r
�ln �_.o !� dl�� bE hartmeni yw-N r a
t4 + � ,;ten
r- - 212` W' Street Sewer/Septic Ylilab l � � tt
R0.011 100 �NaterlWell Avatlabillty
,
�o Two Sets'of'Mctural Plans .�� i,,4: M
3.
_ `i n 413 587 1240 Fax 4 ; >i �Piot/Site
_ Other Specify
j 1'1D['!CA.Tj6N-TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 P- reperty Address: This section to be completed by office
Lot Unit`__-_--
Zone Overlay District_
Elm St. District. CB District___.__..
31: T10;4 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT j
2.1 Owner of i' cord:
2 Authorized Agent:
I _ -
SECTION 3 _ESTIMATED CONSTRUCTION COSTS j
completed b ter „a Off =l Use Only
Estimated c�� �
—a i
B�,.ila ,�6� permit Fee
Total Cost of
i �nst'•-C'i0n from (6))
Building Permit Fee
vW n.:��i;_
I _, Protection i �
4 + ;�_ �( perk ^.umber
This Section For Official Use Only
Building Permit Number: Date Issued:.------- ---_ —_--
SlFnature:
1"widing Commissioner/Inspector of Built nas Date
! A
126 NORTH MAPLE ST BP-2004-0593
GIs#: COMMONWEALTH OF MASSACHUSETTS
MQ:Block: 17A-212 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2004-0593
Project# JS-2004-0846
Est. Cost: $500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use croup: Ronald Mistarka 118693
Lot Size(sa. ft.): 25918.20 Owner: SZAWLOWSKI JOHN R&DORIS E
Zoning.URBplicant: Ronald Mistarka
AT: 126 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
P 0 Box 205 (413) 575-1271
NORTHAMPTON MAO 1061 ISSUED ON:11118103 0:00:00
TO PERFORM THE FOLLOWING WORK:STRIP & SHINGLE 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• Receipt No: Date Paid: Check No: Amount:
Building 11/18/03 0:00:00 1620 $25.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Building Commissioner-Anthony Patillo