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g, DEPARTMENT OF BUILDIJtG INSPECTIONS /=
INSPECTOR '2112 Main Street • Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act as l:is/her construction sups: ,•isor. 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 oven 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
made
>L�; understand the above.
(Home ow r/reside 's signature requesting exemption)
I will call to schedule all equired building inspections necessary for the building permit
issued to me.
Date ` S
Address of work
location 1�
Oz Le AT
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DEPARTMENT OP DUILDD1,1C INSPecT10t.'S
212 Main Strcet ' Municipal Building
Northampton, Mass. 010GO
j ,
«'O114:R'S CONIMENSATION MSLTRANCF A177MAVI-j'
i I
I --
(liccusx/P c rmittcc)
with a principal place of busioessfresidence at: —
— (phoney')
(MT--i/cirj/ atr�TjP)
do hereby certify, under thc.pz_ins and penalties of perlury, hai
( ) I am an employer providing dic following!%vorker's coinocasabo, cove Mge for im
employees ivori3ng on tills job:
(lnninan=Corer,=•) (PcLic:Numhcr) --- (r',pir<aor,Date)
�I _
O I am a sole proprietor, general contractor or homeowner (cc:e one) and h2ve hued
the contractors lined below rho hive the folio%ving workers compen_saaon policies:
(Nam-, of Co_1tnaw) (IRsuranc;; COiTI01R)-il�obc-, !"'UmL<-)
(Name of Conczaor) (lnssranec. Comoazy/Po!im; Numinr) (t_»iT:doa Date)
i
(Name of COIlII-dC10r) (Lnsurance Company[Pol-q- Numbj) (Expirdoo Daic)
(NzMc of Contractor) (Iosurancz- Comparly/Policy Numb-:r) (Expiradoa Datc).
(aas,ch�u::oc71 t3cG,rfacccul-to mdu�iaform�on pa-tn_inins b.11 Dom--_c.o:-s)
I
O I
am 'a sole prop
netor and Gave no one working for me.
( I am.-a home owner performing all the work myself,
NOTE:ple3e>x awtrL tfi,•v 1 }0 6emeo.�ver�u•yo Plc D�ia=La Ji ;v •0, csz=joc r rgair work as.d.-<�-`of
not mote th_o t'ro �itr is t�seh the bomoowoer rvido«oa the F�ou xppurten:�tbcan e r ooc�r-Ay cc=&=,cd to tK
j =MV'0Y= � O=;>--- m Art(GLl 52-a 1(5)),r..pptinaon by a homco--=fr a bt==or permit n_y c6d—the
IrSA of nn es?loyx under dro Wo-k-"Compomat AeL
- r undca.-od th■t a Dopy of chi.mt.�a may tx toronrded to tbo pcp,rcmrnt of In�arri�l ncod�f OCLo.■oC Ir>;ur�nc++for the
covcra.gc real(alioa rutd Riot Liltat to smtrc covernse undo soe oo 25A of MOL 132 m led to the=p sidoa of eimiasl peasltic
coaiirzi g of•ftoc orup to S 1}00.00■rtdjor impruo®at of up to Doc yezr and civil pm,.)tia w tSc form of s Slop Work Order nod■
fi=Of:;I M.00.d_y cpinA Mr-
i
I _ Fa{cp-mm--?1 u. onfy .
Permit NuML--r
Lot
Si�natutr n icroscclPc--
id&A&05 J
SECTION 8 CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
,on 1�E C- rrn mec a ado Not Applicable ❑
Company Name Registration Rum a--fir -- - -
Address Expiration Date
Telephone
SECTION 10-WORKERS'COMPENSATION"INSURANCE`AFFI DAVIT"(M.G:L,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...... ❑
Ill ,
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-year 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 perndt.
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
r
t
.i
SECTION 5-DESCRIPTION,--OF'PROPOSED WORK(check all applicable?
New House ❑ Addition ❑:; Replacement Windows Alteration(s) Roofing
Or Doors ED
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [0 Siding[0] Other[0]
Brief Description of Proposed
Work: £ r+-k-N 1Ac�c.c` c---T"
Alteration of existing bedroom Yes�_No Adding new bedroom Yes JL No
Attached Narrative Renovating unfinished basement Yes ,- No
Plans Attached Roll -Sheet
^s$ ,..: ...,� r'x�:is. ..,�sS.u,., .::., '-
sa ! N'ew�iousean tma ctl#t�go�exis nctio s�ncicornl}tetethea(iciHrr>rt:
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.
1. Septic Tank City Sewer Private well City water Supply
SECTION 7a-.OWNER;AUTHORIZATION-T0 BE.COMPLETED-WHEN
-,OWNERS AGENT-OR CONTRACTOR APPLIES,FOR.BUILsD1NG.PERMIT
1, 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 herb by decla that he statements information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed-LLinder the pains and penalties of perjury.
D+�
ell
Print Naine
(j Signature of O r/Agent Date
~
°
J1Z.(&on 4., Z016� 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
Lot SiVT�
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage
Open Space Footage %
(Lot area minus bidg;&paved
#of Parking Spaces
A. Has | Perm�/Vuranca/Fm� ever been hsuedfor/on the sha?
' x�� �-*
�� �� D�7K�W �� YES
IF YES, date issued:'
IF YES: Was the permit recorded at the Registry of Deeds?
��
NO �� DON . K~"." 0 .^S
IF YES: enter Book Page and/or Document
�� ��
B. Does the site contain a brook, body ofxxoterorvvet|ands? NO �~� DON7K0OVV �_� YES �_�
IF YES, has permit been or need to be obtained from the Conservation Commission?
-
Needs tobmobto[oed x�� Obtained v-� Date
v�� '
C. Do any signs exist on the pruperty �� ��� YES \�� NO v��
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
IF YES' describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,orfi||ing)over 1 acre orind part ofo common plan
that will disturb over 1acre? YEG �`_~� NO K �
� `��
`
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
o Nort hampton
,a.
- �I 'ing Department
i
2,Main Street
4600 100
2044ort�am on; MA 01060
phone 413-5P7-1 0 Fax 413-587-1272
t s t
APPLICATION TT 3 CONS RUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1.-SITE INFORMATION
This section to be co[npleted`by cff�ce
1. roperty Address-
done Overlay"Dlstrict,
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT,
2.1 Owner of Record:
;- , 7 N
Name Print ` Current Mailing Addres C
A UTA —
e(/ Teleph nee —
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 ��L. (a)Building Permit Fee
-
2. Electrical (b)'Estimated Total Cost of
2�ocay. a c� Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5. Fire Protection
6. Total=(1 +2+3+4+5) 000 v Check Number ( Q
This Section For Official Use Only
Date
Building Permit Number. Is"sued:
Signature: '
Building Commissioner/Inspector of Buildings Date
File#BP-2005-1236
APPLICANT/CONTACT PERSON MAZUCH BETTY ANN& ���'SrI fo
ADDRESS/PHONE 67 LAKE ST FLORENCE
PROPERTY LOCATION 67 LAKE ST
MAP 17A PARCEL 238 001 ZONE URB
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid 724 A510 611 r
T_ypeof Construction: REMODEL KITCHEN&BATH
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 FO OWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ATION PRESENTED:
Approved Additional permits required(see below)
PLANNING BOARD PERMIT REQUIRED UNDER:§
Intermediate Project: Site Plan AND/OR Special Pen-nit 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 Commis'
20 or
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.
67 LAKE ST BP-2005-1236
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map.-Block: 17A-238 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-1236
Project# 35-2005-1653
Est. Cost: $10000.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sg. ft.): 10236.60 Owner: MAZUCH BETTY ANN&
Zoning.URB Applicant. MAZUCH BETTY ANN &
AT. 67 LAKE ST
Applicant Address: Phone: Insurance:
67 LAKE ST O 584-5780 O
FLORENCEMA01062 ISSUED ON.6114105 0:00:00
TO PERFORM THE FOLLOWING WORK.-REMODEL KITCHEN & BATH
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 Occupangy Signature:
FeeType: Date Paid: Amount:
Building 6/14/05 0:00:00 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo