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o DEPARTMENT OP BUILDING INSPECTIOI.S —
212 Alain Strcet ' Municipal Building
Northampton, Mass. 01060
V OrUCE- Z'S COIY0 ✓NSA'nON GNSU -Z.A1 CE AI'It'D AVIT
(licz 11 1perm)ru
a PI-mcipal place of businessfresidence at: --
�`v3�
/s., ,/-?,y `:
(phone-!)
(srrr..,c1ci rr/scal c.�ri p)
do hereby cer-61) under the-pains and penalties of perjury:, _hal
( ) I am an employer providing the following %vorker�s cocnocnsadon covemse for Iny
emplovees nvor�Dng on tills job:
(Ianlran= (Polio Nu--abccr) -- (T:-oiradon DaI_)
( ) I am a sole proprietor, general contraaor or homeow-Der (ci c;e one) and have hired
the cone actors lasted below who have the folio%ving Worker's comoen_-,26on policies:
(i+amc 01 C0:=Ci0') (111R!ranc Colno.1,i)YPObc .NU.M*-----) (l=tiJtFdl3ni D.-IIC)
-- (Nzmc of Conramor) (ins-wanCC COMOaati'/Pol c-' NUM&:r) (Ea-pir aon Date)
(Name of Con>zamo,-) Omsuraac; Compan)-/PoUq- Namb:r) (Exair.:doa Daic)
(I`lamc of Conaacior) gzsurmcc Comcaay/PoUcy Numb-:r) 'E. atc) .
(.as[31 iarorm,-:ioa pctaiaias to.0 C=Z--son)
I am a sole proprietor and bave no one working for me.
( ) I am.a home owner perforTn-ing all the work myself.
Ii
1 NOTE:plc=.=be cwzn ts,,+t Ic hcox_o.�vcra ubo caplay P<=u=to eo tz-- ^,= cr rjoa a rt pa-ir work on+d%%mLL_y or
iant aetit tks a 4�str tais in c�'sie+s the b.=o,ro rcs'ca oe oa eb,g-v n zppurtcn=them c.-c ax c=)� _uy==e.-ni to be
eirplayes unc e the..uS ef:x yea Act(G UI 52,=1(5) applia6oa by.bomooavc rcr=Lc-=c a permit m=y ctiidcoec tLc
Icga.l Zzzu of ea cz�loyer under tiro WorScda Com�omaJ,ioa Aa-
i
I uodcsiaad tha a oopy of tbi-mt®-=may be rorwac i d cn tbo DcQartmmt of Induxricl AcadcmY O(Sioo of 6--r a fac Lb-
oovcrzsc%=i mina=d th1 Lilts to sasuc tO%-cm c tack-e Oa 23 A or MOL 152 can I—d to the i=pOsuioa of aimia=I PCmxWc
000st i xg or a finc or up to S I}00.00 uxlor mmrs isoamo of up to ooc ycr zod c%ir Pm.rtia is d C room or.Step Wort Ordc.ad a
f=0(5100-00 z day tpima me
For -
Pcrmu Numbcs -
Stpoa of cc ticc
mi ��� e ���~ -- 1AI
¢�tlf►A1P�.
Lzfy of Northamptian L I
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� �o �lasnachusetfs a
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DEPARTMENT OF BUILDDIG INSPECTIONS /=
INSPECTOR '212 Main Street i Municipal Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 78OCMR 108.3.4 to
act as his/her construction sup(::-z 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 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 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. t
TF+i,o j,nmo�wnnr lnircc ntl ar+rarlac to nA4nrm [1 nA- �P�Pr`tr;i-n1 nhlmhlno� aacl the
11 L.1 11V111�.V YYlllil 1111�J Vl1 11-- — rvaavaaaa •1 va.. �v.vv..aay...., r1___ ___= -- a--i ----
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
r
� k �
SECTION 8-CONSTRUCTION SERVICES t
8.1 Licensed Construction Su ervisor: Not Applicable 11
Name of License Holder: �' `aQ � !Le 7/S�
License Nymbe
� 7
Address
Expiration Date
A,
Signatur Telephone
9-Re"'istered Ho"rrie Tiri°'ravemer►t;Con tractoe:°t- �- - lam
;s Not Applicable ❑
-% ,���� AAa1,1a
Company Name Registratio Nye e�
per. >s-v dJ0;'3 d
Address Expiration Date
Telephone
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.......Ar No...... ❑
�_J._.__i.,dc Q,,yner=ecc---,ied Dwvtlinue of one(1) or two(2)families
The current exemption for"homeowners"was extend ��111�1uua v••...• --
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
f
A
SECTION 5--DESCRIPTION OF PROPOSED WORK.(check all applicable)
New House ❑ Addition []:. Replacement Windows Alteration(s) ® Roofing
Or Doors F1
Accessory Bldg. ❑ Demolition ❑ New Signs [o] Decks [Cl Siding[0] Other[E3]
Brief Description of Pryooposed /�
Work: c./aS'F Its ;1D , Pdti�7Ci S/d�c�t�b'Ila I,
Alteration of existing bedroom Yes I No Adding new bedroom Yes No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll -Sheet
sa F€Nevis klause°a t cl-am ddL idh dt k>s if* oust ncl..cor pW6kt eld oWiric:
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 COMPLETED WHEN
OWNERS AGENT OR'CONT.RACTOR:APPLIES`611 BUILDING PERMIT
S I &3i VA EW(6 _Z_ as Owner of the subject
property r1
hereby authorize C/`p A G /4-041
to act�ehalf,in all matters rel ' e.t4.work authorized by this building permit application.
Signature of Owner Date
I, hr Ala exw as Owner/Authorized
Agent hereby de re that the tements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed un er the pains and penalties of perjury.
e
Print Name
. Da7
Signature of wn r gent te
IF
~
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Section 4. ZONING All Informatibri 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
Rear
Building Height
Bldg. Square Footage %
Open Space Footage %
(Lot area minus bldg&paved
#of Parking Spaces
(volume,&Location)
A. Has aSpecial Perm it/Vahance/Fin�dgi�' enmrbeen issued for/on thasite?
NO 0 DON7KNOV YES 0
'
'
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
t—�%
NO �mw ,o
IF YES: enter Book Page and/or Dooument# |
�� ��
B. Does the dtecontain a brook, body ofxvaterurvvet|ands? NO §�� DON7KNOVV �_/ YES �~�
IF YES, has a permit been or need to be obtained from the Conservation Commission?
'
Needs tobeobtained �~� Obtained v�\ Date
�~� �_� . . .
C. Dn any signs exist on the property ��� YES x�� 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
NO *f�
_ .�
IF YES, describe size, type and location:
E. Will the construction activity disturb grading,excavation,or filling)over 1 acre orisd part ofo common plan
that will disturb over 1acre? YES K ) NO ���
`_~ / ��~
|F YES,then o Northampton Storm Water Management Permit from the DPW iorequired.
City of Northampton SMTu,QF1'ermt
Building department CuICrfiD>►v�wa �e �
212 Main Street seuver�s ptr �,1� � �
Room 1.00 u1are i-VeCrAva�ila
Northampton, MA 01060 F Sets of Steteran �IOU
? s
phone 413-587-1240 Fax 413-587-1272 PIoStte Mans _ �•� r
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH 'TWO F MILY DWEL6N
SECTION 1 -SITE INFORMATION
Thrs- ctro to be cornpl�eted by aff
1.1 Property Address:
pax tx#� S�Ur1tt.�
Zone Overlay DIstrrct r
Elrri StLLDistrct rCB Destrict
SECTION.2-PROPERTY`OWNERSHIP/AUTHORIZED AGENT
2.1 Owners of Record:
/cX$U �^ 1'c�✓�iE /:��llirr[� ,//A /E c }., 2 5 t I
Name(Print) Current Mailing Address:
Telephone —
Signature DEPT Dr�'i'1^";I�$P!(i'ln
riz d # �S
2.2 Autho A en
IVA
Name(Print) Mailing Address:
Signature Telephone _
SECTION'3-E TIMATED CONSTRUCTION COSTS
Item - Estimated Cost(Dollars)to be Official Use Only
completed by ermit applicant
1. Building 00 (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
This Sectforr For Official'Use Only
Date
Building'Permit Number.
Issued:
Signature: r Z
Building Commissioner/Inspector of Buildings- Date
* r
12 NORTH MAPLE ST BP-2005-0770
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 17C-226 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: BUILDING PERMIT
Permit# BP-2005-0770
Project# JS-2005-1078
Est.Cost: $800.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Craig Marney 057159
Lot Size(sg. ft.): 3615.48 Owner: SIENKIEWICZ TODD J&LAURIE J
Zoning GB Applicant: Craig Marney
AT: 12 NORTH MAPLE ST
Applicant Address: Phone: Insurance:
P O Box 128 (413) 586-5512
LEEDSMA01053 ISSUED ON:2110105 0:00:00
TO PERFORM THE FOLLOWING WORK.-ENCLOSE WALLS OVER EXISTING LEAN-TO ON
SIDE OF BLDG
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 ni nature:
FeeType• Date Paid: Amount:
Building 2/10/05 0:00:00 $50.00
212 Main Street,Phone(413) 587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo