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17C-190 (2) j ---__ 1 t.A+SThY t)�,Q '�r57a�Pr - s�1 - jY GGS✓���r�y�'r s.��x 004— Q�KHAM/'7p O Crzty of Xart4ainprtan Z = $ � �tilassac{�nsctts �> 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 his/her construction sups.., sor. 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 tv xp - t59 R t it it S C t t9 > L)EPA[ TINIENT Of' LUILDMG INSPECTIONS 212 Main Street ' Municipal building Northampton, Vass. 01060 WORICER'S COMI-'ENSATION IT�SURANCE A i F-DA IT �:ritll a principal place of businesslre�id•Cnce t: 315y a. (SiTC:Uc7t Cl0 1lCreU�' CCrt1I'1'. Ullac! L}1C t!)i:I}S 3i10 1)CilEi�1C:; Chi pCf�1111', t.i}F!i - I am all empio),ei providin- the i0110`. ii?C {�rr;Crs compcnsamoI] cove'ra C "0' calploycts working (,)n thisjob� ���Siz'i�, ��`7/��y,�x; �. �• GV G^.G 3'ooGoa�O/2voc �� 0 7 (InsuanG Corapam') clic:?�',�Whet) --(`rte—.fir.-non Date) ( ) I am a sole proprietor, genera coninc--O 1,IOr1col.Yver (C'Ole One) and 't;�,-e Iirtd t.hc, contTactorS listed below vi' o 1-2,17-1 the vjOi I:P-S co nnsaw Orl -uo!ill'.CS: (IIIISDC Of COritS ICtGr) n Datc) (Name of COL7i?'C`o-1) -- i31IS�r>nce Coma;�iPGiic' Numcrr) 07-,::;irll ion Date) (1�lame Of Contnct4i) i:G L%a1C) - (Name of Confnctor) — (ian I�I}c Celilr_wr olicy Numl;�) - (I;;p -aior., Dare) ( I "rLTl c. O1C prOl?:]CtUi 2:iff h vc ro OI]C ..'CI ;.!ii` 10„,” 11iI1 a 110i1]C {.WJI]C'r iiCi:C`I1111] �I( iI]� ',v'.)i ii]v'S lly. ZD NO'IT.:plc__ac I':a„-2:c Lila! i]c h cr�o„7m. rnpL• ';*:c c:> _:aac�ct:::_n cn cr::par,c qC d„cl!i c. not u7c«th�.n tf7r-oo uui+�in t,i:id7�hc b.::-.��•aZr-r=-:c>>or«;'��.:�.1::.:>� urtcr_.r1 Lhcctc c:c cr.{(c�xral2'�c;%:::::_::�:a t� to u_� cr tIr tvc:}' s c -a +r.({3'L1,2-=!(S c� p �3 __. hec7co„ cs`cr a L c p. Icgal status of an oa:plo}'er under tLn Wcvi eta Co ~,o ition;A. CL I utsdc_-it..ad Ihs_a copy of tlli�ctatc7s'r.:ay bo faw,vcio-J to t!»IY[inrtzun:of Irdiu:riJ M-ir.�it�Li��or'•'="`r�:c for t1x oovei-rge vcrifilC_Iioo x+.c7d lttat fr..iltii-e to r.z;,u:cot-;r_�.,urd::sc�.iM�S Jl of?.iOI.I S2 can tc�[O[l7e ln7poSllla�Ji c-=�ir_l pec:al;::,� 00=istmi g of a fiat-of up to S 1,500.00 v:''cr i :;7rivr,zti:1 oCup to fir, }-:r P.-.1 civil p=lti" in dK fi T t1 cf a S!r.+`•y' i'-C}1%=_".:1 a Lr�oCS1QG.Q0 a dny tgr_in:.t mc. For cir�%+•'V7"ztsl u.c cnl}' r 5i 1).ti rt: of NS G(�NSRUCTION'SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : ���/�'� l-� 2 a/ 7 X X S License Number Address Expiration Date Signature \ Telephone Reg se e R-ISM mpxoue7rient Contracto Not Applicable ❑ s1/ y Company Name Registration Number t� a 2$ /Z-i / UG133 Address Expiration Date Telephone SEC ��O�QRKERS' COMPENSATION INSURANCC AMDAVIT(WG.L. o. 152, 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)fami: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 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 f6r 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 i SEC�TdO, . `E5� �aTs101+�0`F;PROPOSED�YVORK check all-a I�cab�le � New House ❑ Addition O Replacement Windows Alteration(s) ❑ Roofing ❑ Or Doors ❑ Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks [ ] Siding [ ] Other [ } Brief Description of Proposed Work:R&4-0417,)d.1 j/w"-LJ, 6,1"- Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative 0 Renovating unfinished basement Yes x No Plans Attached Roll 0• Sheet 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. r Mascheck 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 . f. Septic Tank City Sewer_ham Private well City water Supply_ �SSEG�© 1NI�l�RAI�T�IOR[ZATION TO'BE COMPL'E�TED WIiEN OWNS SSA E O CON'�RACTORkAPiES'FOR BILD PL U ING PERMIT 4 v�. `� �z�' as Owner of the subject property hereby authorize �'SIGZ to act on my b�lialf,jn all matters relative to work authorized by this building permit application. Signature of Owner ate 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. °�f'"✓ �� `�,. /�'2-mot: --1 Shy Print Name Signature of Own r/Agent Date Section 4. ALL INFORMATION MIDST 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 L: 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 `" DON'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 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: City of Northampton Building Department 212 Main Street Room 100 Northampton, MA 01060 phone; 413.587-1240 Fax 413-587.1272 t. APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1!- SITE INFORMATION �t � �This�sect�.on to�e':�cQmp:mot` d��b. off�ce�- : 1.1 Property Address: ' g alf S at ` t l�L�✓C ZZ �� O�er1aY �str[ct�� P �r :: "`'b45� I-.$'*6 ,re�" SL _ � :. s� "*t•§��t°^ 'z. District EIrnSt.aDi'stricf ,�,.�, i SECTION 2 PROPERTY OWNERSHIP%AUTHQRIZED'AGENT 2.1 Owner of Record: `I Name(Print) Current Mailing Address: k y - .r Qr , mac ` Telephone Signature 2.2 Authorized Agent: -o ��'�1/ •� s/�� GeJ9oa�avve-' e'�• �� - Name(Print) Current Mailing Address: Signat re Telephone SECTION:3! ESTIlMATED!CONS.TRUCTION COSTS° Item Estimated Cost (Dollars) to be Official Use'Only completed by ermit applicant 1. Building 7 (a) Building Permit Fee Y � r 2. Electrical d v (b) _.stimated Total Cost of Construction,frbr 6 3. Plumbing Building Permit Fee i 4. Mechanical (HVAC) _ 5. Fire Protection 6. Total =(1 + 2 + 3 + 4 + 5) /�/ y `�T Check dumber This Section For Official Use Only Building Permit Number: Date Issued: Signature:' _ Building Commissioner/Inspector of Buildings,, Date File#BP-2007-0777 APPLICANT/CONTACT PERSON John Zieminski ADDRESS/PHONE 8 WOODRIDGE CIRC HATFIELD (413)247-9014 PROPERTY LOCATION 15 WILDER PL MAP 17C PARCEL 190 001 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 Typeof Construction: RENO EXISTING BATH,ADD NEW BATH&INSTALL BATH&HALL REPLACEMENT WINDOW New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/Statement or License 017889 3 sets of Plans/Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INFpifMATION 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 Co n 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. 15 WILDER PL BP-2007-0777 GIs#: COMMONWEALTH OF MASSACHUSETTS Map:Block: 17C- 190 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Cate BUILDING PERMIT Permit# BP-2007-0777 Project# JS-2007-001249 Est.Cost: $14445.00 Fee: $75.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: John Zieminski 017889 Lot Size(sq ft.): 5096.52 Owner: SHORO GORDON F&KATHLEEN M Zoning: URB Applicant: John Zieminski AT. 15 WILDER PL Applicant Atlaress: none: Insurance. 8 WOODRIDGE CIRC (413) 247-9014 Workers Corn ensation HATFIELDMA01038 ISSUED OA:21912007 0:00:00 TO PERFORM THE FOLLOWING WORK:RENO EXISTING BATH, ADD NEW BATH & INSTALL BATH & HALL REPLACEMENT WINDOW 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: Rougher-.Z' -P/ 4 Rough: ��Q 7 House# Foundation: Driveway Final: Final: Final:.. 7 7 Rough Frame: O(c P&)0(Nf i 6E�T !d Re/", cy O i 1 �1/ ,� PLU A,1 A` 1i P ©Z( 2-2f 0'1 L&LA �t Gas: Fire Department Fireplace/Chimney: Rough: Oil: Insulation: 07,(2-z,(0-7 Final: Smoke: Final:0 k 3•/'q .Q.7-12L THIS PERMIT MAY BE REVOKED BY THE CI' Y OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Ce rtificate of Occupancy Signature: FeeType• Date aid: Amount: Building 2/9/2007 0:00:00 $75.006243 212 Main Street,Phone(413)587-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo