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6 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, ke- ` J,f.W099T , Z.AicA t&&Jl understand the above.
(Home owner/residents 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
� e (1�xftr cif ��it1-l(�cilll�lf(111 �.
6 ,z?cssxcflnsctls
m llEP!'�t2ThiEA�I OI' LUILDIJ�G INSPEC710NS
212 Main Street ' Municipal Z3uilding
Northampton, Mass. 01060
WORTCER'S COMTENSATION 1-NSURANCE AI+FMAVI.T
1,v,,ith a principal place of businesslr sidenc
CIO licreby Cerill},_ LTI.I:l- illy p Ms :'.iiC pen itILS of pf:r�llrl',
O I am ao employer provitiin- the foil o`,vint_ ,:,orr_ers compensation covert:"e flor rnY
employces wor�dlig on this job: J
(InstianG Corspam) elic;Number) ---- (E3pir-tion Date)
( j i af1 a sole proprietor, gentral conk or c r hor?cowoer (cilicie one) and ha,,-e lured
t.li;' GOI11T2C1OCS listed be10v ',;iT0 i?� the. iOL 7Pr V� OF&e"s CJ-,7-L) i0 r! o!i1'.CS:
(Name of Coiiu 1mr) ( nS ' 1C COtP.o ;7 �G11L r N 1S 1tYi) T 0' Datc)
(Name of Conti co-) (1-,:) r-a6on Date)
(Name of Contractor) i)I]J I I1C^ (_Ou;:'_ .—01;C: ilo Dat,-,)
- (Name of CoritT
nactGr) -
'.},
C 1 ILTl 11 sole I?1 UI?T1CLJi 2.11 haw-. no OI1C ..'Ur'. i?` fol
• iii'i:
NO•rr.:plccsc be atva:c that:tit a]c kx rco 11rc r. pl >-
-,n;t t a� _f-.:r•r cr:c,�nit«�•,.>;�-:
not tIKYC LIL•a IllrOO L'iltt3 1R tt{`GI tI'.K I:;.:lti:tiZ}?f=-.�z(X CXi
c='.Ploy=-3 utirs the tvc:}, :cc z-_ i n -C,(GLI S2 t!I tjj c w a hn•irourrs:`or a Gcc c c�p:rn:i::: tin c
legal status of as c=Xployer undo thn WcvYcrs Co.;�-lion .cL
I ur>dc.--staad that a copy of thin ctatci:.r_•r]ay bo fcn,t!od to ttrn fYtiartZ,rnt of Inc+suiricl Aci�Lm:f Ci icw oC i:::+.ua-ro for lIx
oovcrtsc VCafic tioa and that fniltszc to tr c coy �ut 3: caiM 2.A of?.{GL.152 �n!cd to tlx impasition of r^r_1 pa aL:s
romst rig oIa fur oftIp to S I S�J.CuJ c;t'.'cr i :;]r..r. c; of;.;p to cr.-j- .:-.I civil pCmI6c3 in llc fcnn c•f a
L•r,z of S100.00 s diy
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SECTION 8.-.CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder
License Number
Address Expiration Date
Signature Telephone
M-h-e'gl"sTe'r'elg'R"o"m'Pr—mt')Fovement�'Contracto ti Not Applicable ❑
Company Name Registration Number
Address Expiration Date
Telephone
SECTION 10 1NORKERS' COMPENSATION INSURANCE AFFIDAVIT(M:G.L. a 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 them
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 n Local Zonino a s and State of Massachusetts General Laws Annotated.
Homeowner Signature
SECTfON S iD�S�RIPW.
TON OF PF20POSED WORK check'0,a71fa Pica le „
� y
New House ❑ Addition ❑ Replacement Windows Alterations) ❑ Roofing ❑
Or Doors ❑
Accessory Bldg. ❑ Demolition❑ New Signs [ ] Decks
[ ] Siding[ Other [ )
Brief Description of Proposed Work: VJW'b of ry& �-�-
Alteration of existing bedroom Yes No Adding new bedroom Yes No
Attached Narrative o Renovating unfinished basement Yes No
Plans Attached Roll D - Sheet D
6a- <f...:earv° ous. : n ;ors:d.dit"i/on to exis#in�housing�co"�mp'he�e the�follo niw�•
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. / -VIA Dimensions
e. Number of stories?
f. Method of heating? 1A Fireplaces or Woodstoves _Number of each
g. Energy Conservation Compliance. 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 .
1. Septic Tank City Sewer Private well City water Supply
SECTIO�� 1t1 R AU�HOR(ZATION 'TO 8E COMPLETED i WHEN'
�.OVYNERS�gGEN CONTRgCTOR APPLIES FO'R BUILDING PERIGIf
I' as Owner of the subject property
hereby authorize to act on
my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
I' 1� d47 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.
Prinj N me
Signa re of wner/A a Da e
Section 4.
ALL INFORMATION MUST 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 Si
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 r
Room 100
Northampton, MA 01060
phone 413-587-1240 Fax 413-587-1272
Qtle it
APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION 1 -SITE INFORMATION
��,, �'�This sectiori�to;b�'�com "Fe#edby'o`ffice�-�rx�,�
1.1 Property Address: r
pR
T7V5 1�/ t �i1L. t . a
off hlt.>; OiO4�1 Zoned
M-� Overla istr of �
.''v
Elm=St DistrictCB Di�irtt
SECTION 2 -'PROPERTY OWNERSHIP%AUTHORIZED AGENT
2.1 Owner of Record:
RkAAAcL --T. k -14-r IERtCA fikhr,l1 3& Aa5bev Gib. -FfafeelcG MA 046;?—
Na (Print) Current Mailing Address:
_g- F,"71-
eleP hone
ignature
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 applicant
1. Building (a) Building Permit Fee
2. Electrical (b) :aimated 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 Section For Official Use Only
$wilding Perm it Number: Date Issued;
l Signature:
Building Commissioner/inspector of Buildings Date
T
32 AUSTIN CIR BP-2004-0343
GIs#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 29-352 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category: woodstove BUILDING PERMIT
Permit# BP-2004-0343
Project# IS-2004-0498
Est. Cost:
Fee: $25.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Group: Homeowner as Contractor
Lot Size(sa.ft.): 15638.04 Owner: KOLAKOSKI MICHAEL&ERICA TRUDELL
Zoning:URA/WSP Applicant: KOLAKOSKI MICHAEL & ERICA TRUDELL
AT. 32 AUSTIN CIR
Applicant Address: Phone: Insurance:
32 AUSTIN CIRC (413) 582-6717 O
FLORENCEMA01062 ISSUED ON.9126103 0:00:00
TO PERFORM THE FOLLOWING WORK:WOODSTOVE
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:�K 7— 3O -Q 3
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS
J
Certificate of Occupangy Occupancy Si nature:
FeeType• Receipt No: Date Paid: Check No: Amount:
Building 9/26/0')0:00:00 359 $25.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo