06-016 ¢�►iAMP�
of Nort ampton
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� DEPARTMENT OF BUILDING INSPECTIONS /
'2112 Main Street • Mmiicipal Building
INSPECTOR
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<:•,Pmsor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or two famit-
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 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
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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DEPNtTMEI-T OP BUILDr,C INSPPCTiol"S
j 212 Main Street Municipal Building
Northampton, Mass. OIOGO
WORKER'S CONITENSA'TTO.N MSURANCE AFFU)ri.��iI"
(liOMSCC/pertni CC)
a principal place of businessfresidence at: -----
(s��t/ci ty/s(atLr�p)
do hereby certify, under the.pains and penalties of perjury:, :hat
am an employer providing the follo%vint iworlrcrs comocnsadon cove g.0 for lily
emplovees wortang on this job:
C I&C-0 41 kdo
I � .
Corer) (Policy Nu_-a}xr) (r;p rrior, D2(--)
O I am a sole proprietor, general contractor or homeow-Der (ci:cie one) and have hired
the cootractprs listed below who have the `oOo i S worker's compen_tat'on policies:
I
(i+IlSIIC Oi C0n- !^Cio') (lnstrancc CoinpanylPo6c Nu h,:-) �tiJLdOQ?l�1(C)
I _
j
I _-
(tit;me of Councior) (LnsuraneC ComoazvRoUL-v `uob:r) (i.\roir.:tion Date)
i -
(Name of Connacto,) amsurauc;Compan)-/POUq- N:vnber) (Expui z6o0 Date)
{
(Name of Contractor) (Lasurancz- ComGauy/Policy Numbu) (Expirtioa Date).
(aas.3:.ddi�oc7!c'xci.ifocc.—x+_^y to it !ucL iafamAzioa pctia.iaaas to.1J
I
O I am a sole proprietor and have no one worldog for me.
( ) I atria-a home owner performing all ti)e work myself.
i
NOTE:plcu be aPrtre tfi•• Lijo hcmco,vcra ,to aaploy pc-cooi w d:) =-4aj a c repair work oa.d..ciLz of
apt tnocz th a ttSOC t^1ia is«',aeh the bomo -.+ =rcmd.o oc oa Lb,Vound,zpputtr^•+-r theca tz oec C-�rlty octr to be
eisploye�unc-e the--kcr s ca=p---1'c.Aa(GUI 52-n 1(5))�z4VUn.6w by a homcoavc far a licx.=or posit cry evidence the
of do Woe..ce.Componvlion AeL
(-Zcra, d tha a copy of thi,-I-may t<foe-.rded b Lb.Degertmaea Aond-&om-of teivr.00a Jr-th.
coven Sc" -Wcxlioa�M UL--t L•ilta•e to"O=)covvrasa undcr 3,Dcj a 23 A of t,(GL 152 ma I=d to the is i oa of cimi"Pc-16-
coasi^..iag of a rmc of up to s 1}Oo.00.r�dfcr 6mPr6-me=n of up to ooc year e.od ckil pm,hio in do room ors Stop Wort:Orden and a
Crsb of s 100-00 d_y Lpiait[Dr_
(" For dcp.rtrxa=...a1 vac oril7 -
f/f Permit Number
tvf
Si&naturc i crniiuee
1,/,z P., tact
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SECTION 8-CONSTRUCTION SERVICES r •
8.1 Licensed Construction Supervisor: y TY -L Not Applicable ❑
Name of License Holder: U it / �/`'� �
License Number
Address Expiration Date
�7 qL4 y'a
Signature Telephone _
xlteatsfece obi * it`p�aceO'oittraa = Not Applicable ❑
Company Name
Registration Num er -----
7'-�fILAh Lowyi y i?v'iGej jNC
Address ,Q )N,�jv,f�j�71�/ - ( �0� Expiration Date
Telephone L? 0
SECTION 10-WORKERS'COMPENSATION-"INS UM: NCE"i4FF(ETAVFT-,(M:G:L:c.1°52;,§h25C(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-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 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
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SECTION'5-DESCRIPTION OF'PROPOSEDW.ORK:(checkalt applicable)
New House [] Addition Replacement Windows Alterations) Roofing
Or Doors 0
Accessory Bldg. Demolition New Signs [C]] Decks [p Siding [[--3] Other[C]]
Brief Description of Proposed c
Work: n eKVW. lk Al Y' 16 S f?y W1Ty'� I'-'TI e-j
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
MGM:
sa_:� Newntose' � ariczrtacrs4 itaarstna�coieeh GM:
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-OWNERAUTHORIZATION,-TO BE COMPLETEQ°WHEN
OWNERS AGENT`OR'E;ONTRACTORAPPUES FO1ZSUILDINCxPERMiT°
- I ` G /Z 1 IN) 3 3 l as Owner of the subject
property c�
hereby authorize �?/// �`5 �.'�.� ' y \/i,- ! Nx _ C tt ec�
to act on my behalf,in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I,
G'11 CG, 74 K Z e%&'` r-) Z'59 -'e) C-0N`�7 S n Le-S !A/C ,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.
Print Name
Signature of O�,er/Agepr Date
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
1
Lot Size
Frontage
Setbacks Front I 7-7 I
Side L: I R: L:' R:
Rear
Building Height
Bldg.Square Footage %
Open Space Footage _ %
(Lot area minus bldg&paved __ I
arkin
#of Parking Spaces
Fill:
volume&Location) IL
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
N0 0 DONT KNOW Q YES 0
IF YES, date issued:;
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book Page; and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO Q DONT KNOW Q YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Date Issued:
C. Do any signs exist on the property? YES Q NO I
IF YES, describe size, type and location: I
D. Are there any proposed changes to or additions of signs intended for the property? YES Q NO Q
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 0 NO 0
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
City of Nortf ampton
Building Department
212 Main Street �e
Room 100
Northampton; MA 01060 e s a
phone 413-587-1240 Fax 413-587-1272a an �
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1'_SITE INFORMATION
1.1 Property Address:
t Thrs secttort to be c0M.P etedbV"�o
Zone Overlay�rstrrct
IEtirn&tDistrrcth C6 E��stFct
_
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT;
2.1 Owner of Record:
P � �y N 3 Y f1 D��ii��� nDr L �eUS
Name(Print) Current Mailing Address: Lj
Telephone
Signature
2.2 Authorized Agent:
z11y5
Name t) Current Mailing Addresse, -iJ� �1vf J'� - (3)WE7
Signature Telephone
SECTf N 3-ESTIMATED`CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building (a)Building Permit Fee
2. Electrical (b)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
This Seetiorf Fdrr Off%eiaC Use Onl
Building P.ermitNum66r.'. Dated:
Issued:..
Signature: r _
i
Building Commissionedlnspector of Buildings- Date
339 HAYDENVILLE RD BP-2005-0941
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 06-016 CITY OF NORTHAMPTON
Lot: -001
Permit: Build na
Category: demolition BUILDING PERMIT
Permit# BP-2005-0941
Project# IS-2005-1311
Est. Cost:
Fee: $15.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use Group: Zaks Construction 054749
Lot Size(sa.ft.): 43995.60 Owner: RYAN MARGARET M
Zoning SR Applicant: Zaks Construction
AT. 339 HAYDENVILLE RD
Applicant Address: Phone: Insurance:
P 0 BOX 739 (413) 527-4440 Workers
Compensation
EASTHAMPTONMA01027-0739 ISSUED ON:416105 0:00:00
TO PERFORM THE FOLLOWING WORK.-DEMOLISH 21 X 45 SHED NO UTILITIES
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 4/6/05 0:00:00 $15.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Comrnissioner-Anthony Patillo