17C-190 (3) ¢•St1AMP�.
_Gritp of 'Wart4aillptan
$ � �Glassac}tusetts -
oan• -
DEPARTMENT OF BUILDING INSPECTIONS /_
INSPECTOR '2,12 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 i:is/her construction sup,,: ;sor. The state defines "Homeowner" as, " Person(s)
who owns a parcel on which he/she resides or intends to be, a one or hvo farm
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 eegulations. 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
Crif� of �QTarflfaIII:p j0ii - _—
4 y f �la3 sit chrzscila' _
a. DEPARTMENT OF DUILDr1\G INSPECTioll'S - —
212 Main Strcct ' h-funicipal Dudding
Northampton, Mass. 01000
W R MR'S COIATENSA-nON CNSUTA-NCE Al,
(IiccvsxJpermlctcc) - - --
wiLl a pn,-tcipal place of business residence at:
(s�.t/cn ty/sza1L�D p)
do hereby certify, under thc.pain5 and penalties of perJury, h:c
( I am an employer providing the follo%ving!workcrs cocnocnscr;o, cove zgc for im
emplovices NvorU(ig on tltis job:
(L2s- ran=Comr,�) (Pclic: N-u-ter) (E:pirzi or Da .)
O I am a sole proprietor, general cona-accor or homeowner(c cie one) and have hired
the coni-actors listed below vybo have the folio«ring worker's coE.2:)tnsadon po.kies:
(Nanlc Of co:,Mcior) (Instranc Coinpan)-Pi oUc-,- Datc)
- (Name of Concracior) (lnsuranec Comoaa}•/Potic}, Numccr) (Li-Dira:tion Date)
(Name of Coa=c-Ld;) (insivanc; CompaDyfPol-q- Nasbu) (Expirdoo Dalc)
(Name of Contactor) (Insuran(-- Compz zy/PoLcy Numb-:r) (E.xp r-dtion Date)-
(aitleh ic:ocJ rScQ.il acoeai--ytn iaroccii'ioa
O I am a sole proprietor and have no one worh3ng for me.
( ) I am..a home owner performing all the work myself
NOTE:pt=-,4 be ewzrc ti—-4 k 6emeo+ven Ito ccmplay peso=to dk) rgau.Qrk oo L d..c1L^ of
an(mecc then `sr-tar r is wbx:h d)x bocnoowoc r,,.da oc ea the U,,u, ,�puric�;tbeen c oo(C=)=Uy Dec d-cai to be
ciIPloycs Act(GUI 52-=1(5)),:.ppti=Eon by a bommaac for a b _or per i ray cvidmcc(L-
la-pl c„*,.of ea<=rloyer uada ttro Work e,coo�emalioa Aec_
[—de--ad tba a ropy of th6 aaL=c a may be foa--,d-ed to the poputmma or i duznel A—&.fy office or Lm—for the
eovc�vC if elioa and t!u L;ltac to seosre eoverase under suevoo 25 A of}tdL 151 cw Ied to the i=p.,I ioa of aimiaal pea w,=
eoar L i of a fine of up to S 1300.00 aztdJor of up to ooc ycr,Lod a ail pea,.hia is d e form of a Stop Wort;Or'de nod a
fim of S 100.00 1 d--y 111 me
For dc9artaav�a,c Drily
permit Numb--r ;
Lot.' �.
+� S i Cnatun of Li.= scrJPc MuUcc — fie
IC
SECTION 8-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable 0
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone
i:C'or di t Not Applicable ❑
i9.:Re is€ere vi�ombeln rave"'�i�eh �racyta.a�. = •. _ -
Company Name Registration Num er _- _--_.
Acldre/s��l Expiration Date
A W _ Telephone LT X19 �a�
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAVkT(M:G1 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...... &3"
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-vear 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
i
SECTION 5-DESCRIPTION tOF PROPOSED'W.ORK(check all applicable)
New House ❑ Addition ❑- Replacement Windows Alteration(s) Roofing
Or Doors 17
Accessory Bldg. ❑ Demolition ❑ New Signs [0] Decks [C] Siding[0] Other[O]
Brief Descnp��l1',p�n of Prop sed
Work: lt;C lYa f4' SD4 �h S/ir%P /na/n hou5'e rid
Alteration of existing bedroom Yes No Adding new bedroom Yes No .
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
6a ff Nevi N oirse ancotFadclittairta extstt>tit�austttg.,:cotiptete the fattotntrrg:
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
L 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 Ta-OWNER AUTHORIZATION-TO BE_COMPLETED WHEN
OWNERS AGENT ORCONTRA�CTOR'APPLIES FORBUILDING PERMIT
I G r'Gt O h J he i- ? as Owner of the subject
property
hereby authorize tyil- 1 I M n QZ e
to act on my 7bef, in all matters relative to work authorized by this building permit application.
a"
Signature of Owner Date
4hereby as Owner/Authorized
Agent 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 o Owner/Agent Date
r
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
Lot Size
Frontage --
Setbacks Front - t
t i � k
Side L: R:l L: R:
Rear (_---=
Building Height
Bldg.Square Footage % L
Open Space Footage %
(Lot area minus bldg&paved
parking)
#of Parking Spaces I
Fill:
(volume'&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
N0 Q DON'T KNOW ® YES 0
IF YES, date issued:,
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DON'T 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 is DON'T KNOW Q YES 0
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 0 NO 0
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES I NO II
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 O r NO
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
.-City of Northampton S
Building Department
212-Main Street SeFel uai fi
n6 Room 100
North;imptoo; MA 01060
pho , ,413-58�-1240 Fax 413-587-1272
r �
Othe> Speer
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
1.1 Property Address: This section to be completed'by office °.
rE
f/a e e Map cot unot
r.Z,otL n e e rn Q Zone Overlay�DEStrrcf-
Elm St District =CB D�stFict
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Gardor,' She t-0 15-
Name(Pn t) Current Mailing Address: ,/
�'�}J� 'v+✓� t/" Telephone
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 appli cant
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=(1 +2+3+4+5 Ud Check Number V
This Sectiori<For Official Use Onl
'Date:
Building Permit Number. Is
Signature:
i
Building Commissioner/inspector of Buildings= Date
c
15 WILDER PL BP-2005-0959
GIs#: COMMONWEALTH OF MASSACHUSETTS
MW:Block: 17C- 190 CITY OF NORTHAMPTON
Lot: -001
Pemut• Building
Category: BUILDING PERMIT
Permit# BP-2005-0959
Project# IS-2005-1332
Est. Cost: $1500.00
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: William Gnatek 100088
Lot Size(sq.ft.): 5096.52 Owner: SHORO GORDON F&KATHLEEN M
Zoning:URB Applicant: William Gnatek
AT. 15 WILDER PL
Applicant Address: Phone: Insurance:
P 0 Box 204 (413) 584-5682 WC
HADLEYMA01035 ISSUED ON:4111105 0:00:00
TO PERFORM THE FOLLOWING WORK:REROOF SOUTH SIDE MAIN HOUSE
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 4/11/05 0:00:00 $25.00
212 Main Street,Phone(413) 587-1240,Fax: (413) 587-1272
Building Commissioner-Anthony Patillo