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17D-021 (8) O¢.ttU1A1P�O �-� of Nart4amptan L �} �dS�A[hli8[tt9 DEPARTMENT OF BUILDIN G INSPECTIONS / INSPECTOR 212 Main Street • Municipal Building Nortlrtmptcm, 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<_: 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 accessoty 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) Ind 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 r 0ti� CyI of �rrrfl�al)t}�toll _ p .. � r�t3ateCh narlfa' a DEPART MENT OP BUILDrNG INSPECTION'S 212 Main Street Municipal Building i ' Nort.hampton, Mass. 01060 I WORIC ER'S CONITENSA'nON MSURANCF AI=I A VII (li MML--:clperm)tICC) \%IiLh a piZrtcipal place of business residence ,at: 01 (stT�t/city/szaiclri do hereby certify, under the pains --ad penalties of perjury; hat ( ) I am an employer providing die followine workcr's compenscaon cove—ge Tor Im etUptovccs wor-bog on 0115 job: (II>S1Lr'�+ Conr c)) (Polic: N=abc_r) -- (r':-pinion Day.) V/1 am a sole propr,ctor, general contzactor or homeow-Der (ci cie one) and have hired the contractors listed below who have the following Wockes coaioenszaon policies: 01c�.^pee- D (LNaMC 0 C0::':-'.CZ0 (IRSlI-7Il C COIT1D1r1)'/�GUC; ?�r1101n :) (r?-�ITJ60t DIIC) ! MZMC of Contrelor) (1nsJranec Comoa.n,iPo6 \tiocrr) (Expiration Date) i (Name of Connamdr) (Insurance Compa.n)-RoUcy Nz=bzr) (1=-,,:pim600 Date) (Fame of Conaaetor) (insura.n= CompazffPoUcy Numbzr) (Expi-abon Da1c). (a- :ddiCOcsl-b--f ifac .y to ir><vd=iafom.,.;oo patniains to all coal-1c:a) (L411 am .1 sole Prop mwi and bave no one working for me- ( ) I am.a home owner performing all the work myself. NOTE:pl=u be aWlre(fit'K{_} 6omeouvcn Ktio cpjay p,.am to cio_r,20= o,-,O C rcpair warx o1 l d-TJI^Z of ont toxt ltw Lt---tmrr is ta-bicb the bomeownc rr id,=or oa the 17oewcb z,�purtenri tba- L-r ooe C=sr,2y oc=.dvmd w be loyca un,e the K¢t oc:�oa Act(GL151=1(5)�:.ppli=L6cm by a bomma-=f=c bey--cc permit rc_y e.-tdmcc tM Iesal cwu of e-a axployx coder tiro Work a'a C c:3'> alioa.AaL - [uadcruad tba a copy of thu cw—=may be fog -d.+d tt+tbo Dlpe,cna of Icdattri cl Ao dr.AY OM oC layricoa for the covcxCc v aZc ioo dnd th:t U-=c to scour,covcrnsc uOdcr soctjoa 25A of t.(oL 151 r3.a Icd to the taPo,s ioa of ci Mi peri 6- 000sism of a fine of up to 51.300-00 arWOC of up W ooc year e.od coil pcnxpjm is t,form of a Stop Work Ord--nod n rr=of S 100.00 s d y Lptiva CY- FP t" t Number L7 � �_ Lot ^ : ce J S;�zi n of Li crmiucc -- r SECTION 8-CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder License Number Address Expiration Date Signature Telephone 9es all Not Applicable ❑ Company Name n Registration Number Address A Expiration Date -�— Y/J c (/Cc �L�"'"Telephone 7A���Gh SECTION 1'0-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(t 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 Alteration(s) ❑ Roofing Or Doors 171 Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [M Siding[p] Other[ED] AIK 17 Brief Description of Proposed Work: J� < f IA Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll -Sheet r;.._. -,_.r-3"•&. ':R`#, .3sv..t?✓ .;.a `.'�.�•- a;"''S xx',°. �.a�.',;. '..t »ems.;# ry� .a'.u�°u, .:�.'i, '�"'°-,c'fir�"*c :iX^•f ri!..-: sa �f Nei�liose anon d�tlor> a e�cistinci hoes>kng,zcbrririeeellog: 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 7a-OWNER.AUTHORIZATION-T17 BE`GOMPLETED ;WHEN OWNERS AGENT OR'CONTRAGTOR APPLIES FOR BUiLDING'PERMIT'I Ox 7V, h/' fi-Il1l�— as Owner of the subject property hereby authorize to a t on my behalf, in all matters relative to work authorized by this building permit application. blgnatur4 of Owner Date ?Q0V �,�/ ,(// as Owner/Authorized Agent hereby declare that the stateFnents 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 %me' ign wnedAgen Date A Section 4. ZONING All Information 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 Side L: ! R: - L:'-- R:;- e Rear -- Building Height Bldg.Square Footage % , Open Space Footage % ----, (Lot area minus bldg&paved I t parking) r #of Parking Spaces Fill: volume&L.ocation � A. Has a Special Permit/Variance/Finding ever been issued for/on the site? NO DONT KNOW 0 YES 0 IF YES, date issued:l 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 DONT KNOW 0 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 IF YES, describe size, type and location: s D. Are there any proposed changes to or additions of signs intended for the property? YES 0 NO C) 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 NO IF YES,then a Northampton Storm Water Management Permit from the DPW is required. . r _ �.---"--•, ', � � �� r� ��De"� 'erase-on1�� � � � � n ~� ''\'Cit� p of Northampton tatu?;of R ��uilding_Department ` U — 212 Main Street 6 Room 100 �orth�mpton, MA 01060 w R phone, 3-581-1240 Fax 413-587-1272 a � MAIN AOLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 -SITE INFORMATION 1.1 Property Address: Tfil secfion to be com pleted by-'- ce a M f lc Zone. Over ct Elm St:-District:".` CB Distuct - SECTION`2 PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record: �i} GL�I��'��xr � f���//s�',+✓r� �© /sa-� ���d�' a ', � Gl��- lame(Print) Current Mailing Address: . �,.^ Telephone SiEngQre 2.2 Authorized Agent: Name 2:1-.. Current Mailing Address: 6/t3) �� 7- 1`7-77 Si atu r Telephone SECTION 1 ESTIMATED CONSTRUCTION COSTS- Item Estimated Cost(Dollars)to be Official Use Only com feted by ermit applicant 1. Building �y� � (a)Building Permit Fee 2. Electrical f (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) 61,1141111.6 Check Number This Section For Official Use Only Date Building Permit Number. Issued: Signature: Building Commissioner/Inspector of Buildings Date BP-2007-0105 GIS#: COMMONWEALTH OF MASSACHUSETTS CITY OF NORTHAMPTON Lot: -001 Permit: Building Category: BUILDING PERMIT Permit# BP-2007-0105 Project# JS-2007-0162 Est.Cost: $5200.00 Fee: $25.00 PERMISSION IS HEREBY GRANTED TO: Const.Class: Contractor: License: Use Group: GENE BOROWSKI 146933 Lot Size(ssg. ft.): 9583.20 Owner: CAHILLA�r-_n ITA M Zoning:URB Applicant: GENE BOROWSKI AT. 105 STRAW AVE Applicant Address: Phone: Insurance: 5 1 A CLARK AVE (413) 687-3777 NORTHAMPTONMA01060 ISSUED ON.712712006 0:00:00 TO PERFORM THE FOLLOWING WORK:STRIP & 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: Ho u s c Foundation: Drioc»: ,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 SiLmature: _ FeeType: Date Paid: Amount: Building 7/27/2006 0:00:00 $25.00MO 212 Main Street,Phone(413)X87-1240,Fax: (413)587-1272 Building Commissioner-Anthony Patillo