17C-148 (7) O O
Gl ity of Xart aiiiptan
Z
� j�rlassaclruseffs � _
DEPARTMENT OF BUILDDvG INSPECTIONS
INSPECTOR 212 Main Street • Munic:ip11 Building
Nortli�nPton, 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., .-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 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 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
o4-f,v.�rP�o
ti cif ) �f I _
a DEPNtTMEITT OP DUILDD\'G tNSPECTio),S
212 Tfain Strcct Municipal Building
Northampton, Mass. 010GO
«'0 RICE IZ'S C0I'AP E NSATI0N MSURANCF A1=1 A M-
\VILb a prU-1c1pal place of business/residencc at:
(shone:-) fit',
(stt/city/ a(riZ:ip)
do hereby certifj-, under tie pains 2nd penalties of pcgury,, :hat
( ) I am an employer providing die following %voriccr✓s comocnsadon cove rage for Im
emplovecs %vori3ng on this job:
(Tana-mac Cocsrac�) (PaUc: Numbcr) F:pinion Dpic)
( ) I am a sole proprietor, general contractor or homeowner (ci c;e or_e) a_nd have hued
the conuactors listed below who have the `oUo%viog workef s counens2aon policies:
(Nl arnc o-Co tMaor) (In_2M11CC Corno3J-1)-1P1cuc; N'umhr:) (->.�ITJU?? I�11c)
(Name of Coomaor) (Lnsaraac ComoazytPolier Nuzn-rr) (i:xvir26on Date)
(Name of Coaaaclor) (IzLsurancc Company(PoUq- Namber) (Expirrtioo Date)
(Name of Coatmaor) (Ln. =ar CompanyNoLicy Numbs) (Expiration Datc) .
(aIIac(l: i�ocxl rScd.if nocc• iafortaa;oo;_�In.0
(X I am a sole proprietor and have no one worming for me.
( ) I am.a home owner performing all the %vork myself:
NOTE:plcsc be ao ut rh,. IzLk liamco�vcta wbo cmv loy pc sons w rSo .ss�o=-.:c,ao c reds—or?m of
Got moct tbL'-nr-smrs in abi6 the bonx>owocr raid=or oa the l7Duo6 a,puteari tscr=L-r oot C _Dy ooa:d.-roi o tc
eiZPlo)-es uaGe thekefs a _xioa Aa(GLlS2=I(5)} _pplia600 try a bomeoava fcr:lice.cc p=ma r=y a idenee ttc
Icgs1 eta 3sc of en-=Playec uodar dio Work4e,Compomati AaL
[u dcrrtaod tbd x copy of thi,mt®ca my be fod<d to Lbe Dopercmccd of 1.6'jicl Ao&..fy Omoo or L---ror th.
oovcfa vaZc=z'oa a_'fd Uu U-='c to ceauc)covcrase under roc.boa 25A cf t.(GL 152 an lc td to the'_;=tioa of c:imio_-1 pea llio
coo=3L=&of a fiat orup to 51300.00N mpruoosncy of up to ooc ycW rid civ1 pco ria it,!>'form ors stop Work Ord=n.ad.
fl=of S 100.00 a d_y Lpin a me
For 6ep.rtm— u,e oaty
�.1;10 permtt Numt�
tl V h'L7n. Lo( .
SiteaSWIt f Li crrrtit(cc -� J
r V -.
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor:
t� - Not Applicable
❑
,
Name of License Holder: c 'ti�Ll. ,a Ayt c . IL t d t S 01 (( 0
License Number /
Address Expiration bate
9i�
Signature Telephone
>1tegisterei(>�dmeiiipfoveinenfontrazto `�� Not Applicable -❑
Company Name . Registration Number
Address Expiration!
r^
W bl-t44 C. t AILA Telephone ' 1 7�
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...... ❑ '
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
SECTION 5-DESCRIPTION OF PROPOSED WORK(check all applicable)
New House [❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors 0
Accessory Bldg. ❑ Demolition ❑ New Signs [p] Decks [M Siding[0] Other[01
Brief Descripption of Propose
Work: S�y c,d e n5 [vr� rt ewc� c r«-..•nib{
Alteration of existing bedroom Yes_ J No Adding new bedroom Yes !o No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
# :r>., .-,.:s,." .._.. °rx. rf, ^e� '� m,e.. .:arY ^:. ?t-
sa 1f�iew,hotase andaoria ditror 'tozex�sfinarhd sins arrrpfet t ego�owma:
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.AUTHORIZATION.-TO-BE`G.OMPLETED WHEN
OWNERS-AGENTOR'CONTRAGTOR.APPLIES FOR,BUILbiNG PERMIT"
�j I, Pell `t�(�_�-- , as Owner of the subject
property
herebyauthorizeC. P4-,[,0 Ana I�na ✓Llk- Jo
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Da
I r\ ��! r! t 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 Owner/ gent Date
. �
,
Section 4. ZONING All Information Must Be Completed. Permit Can Be Denied Due To Incomplete Information
Existing Proposed Required by Zoning
nis column to be filled in by
Building Department
Lot Size
Frontage
Setbacks Front
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(1-ot area minus bldg&paved
#of Parking Spaces
(volume&Location) ij
A. Has a Special Permit/Vahance/Fndi ever been issued for/on the site?
NO 0 DON70N0W 0 YES 0
|F YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
'
NO 0 DON7 KNOW 0 YES
IF YES: enter Book Pag and/or Document#'
'
�� ��
B. Does the site contain a brook, body ofwa� �� VV�ur�et|ands? NO �_� DONT KNOW ��_� YES �_�
IF YES, has permit been or need tobe obtained from the Conservation Commission?
Needs to be obtained �� Obtained �� �� |��d'
x_� k_/ ' '
C. Do any signs exist on the property �� ��� YES �~� 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 xD
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,gradingexcavation,o,filling)over 1 acre orioa part o�o common plan
that will disturb over 1acre? YEG ���) NO ���3
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
`
�, � De�aartmen�.use on�� r
ity of Northampton Stafus�oFett � �
�n M
`', wilding Department rl}Or�UIIraye��
212 Main Street We tla +�
Room 100 ate
l U, abtlit� �
Northampton, MA 01060
phone 4 A3-58 1240 Fax 413-587-1272 fot# ians � -
i
PLICATION
rAP
`^ � TO-COiQSfR�UCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION'
This 5ect�on to be7completed by office
1.1 Property Address:
llnit
tic - �� Zone O�erlax Drstnct
EIm St�'DistG�ct CB;Distnct =SECTION'2-'PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
rare \ Para'v-
Name(Print) Current Mailioa AdCdrress:
-k'a L —Q-C�" Telephone
Signature
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone-T SECTION1-ESTIMATED CONSTRUCTION-COSTS-
Item Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building ICJC}t � (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=(1 +2+3+4+5) Check Number Q
This Section For Official Use Only
Date
Building Permit'Number. Issued:
Signature:
Building Commissioner/Inspectorof`Buildings Date
BP-2007-0226
GIS#: COMMONWEALTH OF MASSACHUSETTS
r.2
CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category BUILDING PERMIT
Permit# BP-2007-0226
Project# JS-2007-000345
Est. Cost: $4000.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: C PHILIP ANDRIKIDIS 150673
Lot Size(sq. ft.): 10890.00 Owner: HARPER KAREN&THEODORE
Zoning.URB Applicant: C PHILIP ANDRIKIDIS
AT. 33 KEYES ST
Applicant Address: Phone: Insurance:
52 MAIN ST (413) 585-9171
FLORENCEMA01062 ISSUED ON.812912006 0:00:00
TO PERFORM THE FOLLOWING WORK.-STRIP, PLY & 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: Date Paid: Amount:
Building 8/29/2006 0:00:00 $25.001090
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo