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'i" :: DEPARTMENT OF BUILDING INSPECTIONS _ _. _
INSPECTOR 212 Main Street • Municipal Building s •
Northampton, MA 01060
e
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: Hsor. 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 struct 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 backfiIl)
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
{
F (- `� �yti (yri12 of Norfl h amptoi1 i _
4 e t e �7 f �Zasanchntclla' •
• L•�.�.� _
DEPARTMENT OP BUILDING INSPECTIONS , -
212 Main Street ' Municipal Building
Northampton, Mass. 01060 r''
WORKER'S COMPENSATION INSURANCE. A VFW AVIT
I, _ _
� j1q :.•-'_ // Q - -- --- - --
(Iicc s dpermittec)
with a pr,-lcipal place of business/residence at:
[ e koi" ,x0,1, f, i,.(c1/,.�� ii//l, ( phone:" ) m -- s 1 ,1 ? c
r—
(a t/ci ty /state /a p) -/
do hereby certify, under the pains and penalties of perjury hal
I am an employer providing the following worker's comocnsaz ion coverage for any
employees working on this job.
n c: , c t . - a/ 6c_ . S "Gc-AS',/ yi 'C . .007 o 7 ..
_ Qnsurnce Company) (Pclic: Nu_�airr) (E : •lion ate) .
( ) I am a sole proprietor, general contractor or homeowner (cir cie one) and have hired
the consactors Used below who hive the following worker's cooDen_adon policies:
l i
(Name of Co„rcto 1 (Innlfancc Company/1)06c; Numh. ) (1:_xptrnQn Date)
(Name of Contractor) (Iiis Comp Nuuiicer) (LYpir.:tion Date)
(Name of CotTraao;) assurance Company/Policy Nambu) (Expiration Date)
(Name of Contractor) (Insuraucc Compauy/Policy Numbs) (Ex Date) .
(aa.cta -: itocsl rScct if nccc a -y to mead; inforea... oo pczr.f�inr to ..I.1 coca —corm)
( ) I am a sole proprietor and have no one working for me.
( ) I am .a home owner performing all the work myself.
NOTE: par_.. be .w-arc du: w', )e bcmcowocra w'6o =ploy pcsom to do r.:.- cs..:rr «repair wort on . dw<h•. of
one mote then tbo: =its in whir, the bomoowvcr raider or oa the ao ort�t r.ppurtccuua tbetSn err ox c-x---lly oecsd. --oi to be
■
eaploycs unl c the w, oc . o ucc Act (GL152 =1(5)). pplin000 by n bomcow-oc for a lies « permit may 00 the
i
1091 ctsau of en e uods-r Ciao Wockola Cocapom+tioa Aa_
I uadc•ataad tad a copy of thin a a t c m c m osn.y b..100•" to tbo Dopartma st of 1 •+h• =r*icl Acadoots' °Moo or 1 . 'one for the
• ooveabc vcria= ion and tltu L-iltac to sxurr bovcrasc talc roc ion 25A of MOL 152 eta 1 .4 to tbo iatpositioa of e-itaiasl pc -cuaia
psi- sag of . floc ()Cup to S 1 S00.00 and/or iraprisoaracas o r up to one r_ar end civil pmatia in he form of. Stop Work Or and a
rtm x(5100.00 a day 11.E2-i= the
• For dcauta+:7=-1. u+c only
/ Permit Number
,r _ /� .y Ail mape __ Lot °
r .• tutrc of ._ ' . •crrniucc Date - - - ¢
A•-
/9
. 4
ECTION 8 - CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
� /f ` c° ��o 30-�
Name of License Holder : e j,A.i C n n1 �
License Number J - ` g
"c /0"r� �/ , S /. a /
As . Expiration a te
/1 _. - 4 111 ..dra _40 - ..... .—
if ure Telephone
9 ' Register' ed' Ilotrie'Tmprovementtori =' - - " x `�"' Applicable �,�,: _��;..���� � a ..� �. °. Not livable . ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G c. 152, § 25C(6))
r i Work ers 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 ❑
11: �rx..Hor 1K ner em rori
The current exemption for "homeowners" was extended to include Owner - occupied DwellinEs 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 be /she shall be
responsible for all such work performed under the buildinE 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 CI
Accessory Bldg. ❑ Demolition i t 0 4 New Signs [O] Decks [[J Siding [0] Other [0]
Work:
Brief of Propose0 �, :4 4 C� /teGA./* /7: 0
Alteration of existing bedroom Yes No Adding new bedroom Yes _ No
Attached Narrative Renovating unfinished basement Yes No
Plans Attached Roll - Sheet
4:A a ii/Afaa - 6 r:'d - gatit ort iOttgit , comp a rtheWoNowiriq:
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 -s OWNERAUTHORIZATION - TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I. ,/ ,e/)4/ nent,41,.5.0 (i4P4/Q.P.,0,4_, i , s Owner of the subject
!"� roperty % 7y441. � 4.a'
•
hereby authorize i Ir .44.: 1'
r
to act on my behal , in all matters re .tive to work authorized by this building permit application.
1 ,..l......',464(.. Ci /l riLLai!.!! ✓� iii �.�..r. •
Signature of Owner Date
1 • I/ I, `� �� : , as Owner /Authorized
Ag 7 hereby de - e at the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief.
Signed nder the pains and penalties of / e � rj - u � ry.
P me
1 )':,,e 'i��t �/ I�
S' •'lure of Ow - A. - nt 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 " 1 / r
Frontage
Setbacks Front
Side L: R: L:' R:l
Rear `JD ' .
Building Height /
Bldg. Square Footage
Open Space Footage %
(Lot area minus bldg & paved `
i
parking)
# of Parking Spaces
Fill:
(volume & Location)
A. Has a Special Permit /Variance /Finding ever been issued for /on the site?
NO 0 DONT KNOW es YES 0
IF YES, date issued:
IF YES: Was the permit recorded at the Registry of Deeds?
NO Q DONT KNOW YES 0
IF YES: enter Book Paged I and /or Document #
B. Does the site contain a brook, body of water or wetlands? NO DON'T KNOW 0 YES Q
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained Q Obtained Date Issued:
C. Do any signs exist on the property? YES 0 NO t ),e4
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property ? YES Q NO
$
IF YES, describe size, type and location:
E. Will the construction activity disturb (clearing, grading ex vation, or filling) over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES 0 NO
IF YES, then a Northampton Storm Water Management Permit from the DPW is required.
L
Fz --4 D a h_ 0 ®S a ns "P" w " "" {
City of Northampton
Building Department 3 tea_
212 Main Street e ` ` ��
�r� Room 100 z . ,
- Z �' Northampton, MA 01060
`' phone 4:13 -58 -1240 Fax 413 -587 -1272 ? a r ° �
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 - SITE INFORMATION
1.1 Property Address: ,
Th is section to be completed byoffice
7 ,4 . Gl/ /� J Map lot Unit
/� �O/fi �� �/ 0A,F OueriayDiafnct
4:2/ 44 � F w . 3 °
E lifl .Zt bistrict w ` CB,�IStrlc .. ...
SECTION 2 PROPERTY OWNERSHIP /AUTHORIZED AGENT 1
2.1 Owner of Record:
cS.9./Vdle,; L. J »OMADt?,t1 � sJ
Name (Print) / Current Mailing Addres/
S C'. /c L5� 3/
��i -etL — i _ �_ ' ' -.-i Telephone /� �%'..e ∎ i % J)
Signature % /-/ yig?
2.2 Authorized Agent:
, / ' ' 0 Ai r/ e--ge) 0 A
Na e (- ;nt) Current Mailing Address:
1 1, // . y77 3 ?
re Telephone
SECTION 3 - ESTIMATED CONSTRUCTION COSTS -
Item Estimated Cost (Dollars) to be Official Use Only
completed by permit applicant
1. Building / � �^y (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 '509/ Q
This Section For Official Use Only "'777
Date
Building Permit Number. Issued:
Signature:
Building Commissioner /Inspector of Buildings Date
File # BP- 2010 -0249
APPLICANT /CONTACT PERSON DINO MARINELLO
ADDRESS/PHONE 398 RIVER RD SOUTH HADLEY (413) 536 -2596
PROPERTY LOCATION 78 HAWLEY ST
MAP 32C PARCEL 228 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Fee Paid
Typeof Construction: DEMOLISH GARAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner/ Statement or License 300
3 sets of Plans / Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFO ! ATION >PI SENTED:
!'':proved 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*
ye , V n'1vs�
Received & Recorded at Registry of Deeds Proof Enclosed QjQpd / Qe
Other Permits Required:
Curb Cut from DPW Water Availability Sewer Availability OA 517
Septic Approval Board of Health Well Water Potability Board of Health e•Coi✓O /72.S
Permit from Conservation Commission Permit from CB Architecture Committee Ave, pfrpo
Permit from Elm Street Commission Permit DPW Storm Water Management
COP" "
Demolition Delay
Fr zoo'
Signature of Building 0 ficial 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.
File # BP- 2010 -0249
APPLICANT /CONTACT PERSON DINO MARINELLO
ADDRESS /PHONE 398 RIVER RD SOUTH HADLEY (413) 536 -2596
PROPERTY LOCATION 78 HAWLEY ST
MAP 32C PARCEL 228 001 ZONE URC(100)/
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out /�/
Fee Paid L99/ 0/ 57--
Typeof Construction: DEMOLISH GARAGE
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included:
Owner Statement or License 300
3 sets of Plans / Plot Plan
THE F LO WING ACTION H AS BEEN TAKEN ON THIS APPLICATION BASED ON
IN ATION 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 Commission Permit DPW Storm Water Management
Demolition Delay
Signature of Buil ing 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.
TIMMY ST 4 BP- 2010 -0249
GIS #: COMMONWEALTH OF - MASSACHUSETTS
V ap:Black: 32C • 228 4 CITY OF NORTH IPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED' CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Category: BUILDING PERMIT
Permit # BP- 2010 -0249
Proiect # JS- 2010- 000314
Est. Cost: $4995.00
Fee: $20.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: DINO MARINELLO 300
Lot Size(sq. ft.): 6708.24 Owner: ROGALSKI FLORIAN
Zoning: URC(100)/ Applicant: DINO MARINELLO
AT: 78 HAWLEY ST
Applicant Address: Phone: Insurance:
398 RIVER RD (413) 536 -2596 WC
SOUTH HADLEYMA01075 ISSUED ON:9/17/2009 0:00:00
TO PERFORM THE FOLLOWING WORK: DEMOLISH GARAGE
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 9/17/2009 0:00:00 $20.00
212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272
Building Commissioner - Anthony Patillo