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DEPARTMENT OF BUILDDNTG INSPECTIONS
INSPECTOR '2112 Main Street • Mmricilll Building
Northampton, MA 01060
HOME OWNER EXEMPTION ACKNOWLEDGEMENT
The State of Massachusetts allows the homeowner the right under 780CMR 108.3.4 to
act a4lis/her construction super sor. The state defines "Homeowner" as, "Person(s)
who owns a parcel on which he/she.resides or intends to be, a one or twofami�
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 f egulations. 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
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4-cttAMnT t..
„� .E Crii� of ��arfljalit}�tot) _ _-
gl E _ —
+3*itch nsr!!a' _
o DEPART MEI-T OP DUIIDf)\G INSPECTiol S
j 212 Main Strcet ' MunicipnI Building
Northampton, Mass. 01060
I '
I «•'O RIC:R'S CO lIfP EN S A'nO N MS URAh CE AF TI=
d (l�cx-us�Jl�cr'ml ttcc�
V,rith a pr',-lcipal place of businessfresidence at: -- --
,hone'
ty/statLt ri P)
do hereby certify, under tbe.pains acid penalties of pcgur-y, that
( ) I am an employer providing die Following compcnsabon cove.-- for 1ny
emplovees wor-Long on this job:
(LnnLr� Comp ) CPolic-'NtL r) -- (r;piraor.Dz,-)
( ) I am a sole proprietor, general contractor or homeowzler(ci cle one) and have hired
the conn-aclors listed below who have the fobollvin2 worker's compensation ponies:
(INam 0, con=.ci0r) (Insurano Compan)vholic.; NUSI1L:-) �tiJIFdGO'l�11C)
- (Name of Corivaclor) (1rLSUranc COMDanVIPOUM, N1Lmcsr) (E»ir Don Date)
(Nzme of Coaa-aelo,-) Gmsurancc Compan)-/Pobq- Number) (Expimrion Date)
(Name of Contractor) {Insurance Comezuy[Poliey Number) (Etpitzdoa Datt). '
(aas.C:]adiiocs!L'taC,if accca..:y to a�c!vc�iafortn,�-i oa pctaiains to.11 acc=-=-3)
N I am 'a sole proprietor and have no one wori,-iog for me.
( ) I am.a home oNvoer perform,mi g all the work; myself.
NOTE:plcx be ewyC tfi,•utJe bem ,,,,In wtO cmplay pccom to do r rcpzir wark as.d. J1_Z of
aot mort tbea t'Sae �is v�i�the bomoo+.wc rtmdo or oa the p-oc,ac:,zppurtco at tS=C'0 e-r oa G=�r.Ry cecr:d=ai w be
cirplaycs t= the-=k=''z C:pcIim Ac(GUI 52-=l(5)�=pplinboo by a bomaoa-aa for a 6c=or pazait rs_y,c%idcD-tLe
legsj nano of as-: layer und'-r dip Waecxea COcmpa, voa Aa-
a [uad--*s.nad tt�d a Dopy of thin mtcm.�mry ba focv.�vded to tbo pcqutscot of lndtizri..!M.dd—&Office of 4u+r+voa far tb.
cav�sc Y=i Czlioa and tltl L•ilrzc to tca=toverasv I ioetioa 23 A of MGL 152 can ted to the i=Pautim of aimiust pea W=
eoa: ag or a SOC ortP to 51300.00 andlor of up to oae yr=r rod civil pmaltia is the form of a Stop Work Order and a
rrm of S 100.00.d--y.piast me
For dm.rtaa--�,,u,c Doty
d✓ permit Numt--r
p: Lot
Si�naLUrc of Li ct�rtiucc —fie - _- .)
SECTION 8-CONSTRUCTION SERVICES �
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder:
License Number
Address Expiration Date
Signature Telephone _
9 .Re isle £o' iieili �o�reiYreoit acto "' Not Applicable ❑
Company Name Registration um er —--
Address /� ( Expiration Date
Telephone �O' r C J t -j u
SECTION 10-WORKERS'COMPENSATION INSURANCE AFFIDAv (M G:L.c:1W,.: 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...... ❑
i
The current exemption for"homeowners"was extended to include Owner-occupied Dwellings of one(1) or two(2)families
I
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 Lad State of Massachusetts General Laws Annotated.
Homeowner Signature
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SECTION 5-DESCRIPTION OF PROPOSED WORK(check�all-aaalicable)
z_
New House Addition ❑.. Replacement Windows Alteration(s) ❑ Roofing ❑
Or Doors M
Accessory Bldg. ❑ Demolition ❑ New Signs [01 Decks N� Siding[0] Other[O]
Brief Description of Proposed
Work:
Alteration of existing bedroom Yes No Adding new bedroom Yes Yes No
.
Attached Narrative Renovating unfinished basement Yes
Plans Attached Roll -Sheet
3 u4*. r'�`°3-u° '-�
sa_I Nefro"use c acic�tcac> o exls.- mm-,WI ci rsl tc.m,coropiet r fo _I�la:
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-ORCONTRACTOR"APPLIES FOR BUILDINGaPERMIT
as Owner of the subject
property I�
hereby authorizeCt�V '�
to act on my half, in all ers relative to work authorized by this building permit a plication.
l / j �� 1
Signature Owner Date/
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.
Print Name g
Signature of Owner/Agent Date
rir 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:' _ La� R
t
Rear
Building Heights - —
i
Bldg. Square Footage r—j I %
Open Space Footage % r—=
(Lot area minus bldg&paved -
arkin �
#of Parking Spaces E
Fill: ? I
(volume,&Location)
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
N0 0 DONT KNOW YES 0
IF YES, date issued::: 1
IF YES: Was the permit recorded at the Registry of Deeds?
NO 0 DONT KNOW 0 YES 0
IF YES: enter Book PageE i and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO 0 DONT KNOW YES
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained 0 Obtained 0 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 0 NO
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,pxgavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES Q NO
i
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
d
;Clt�of Northampton
B6>i 'in g Department
212 Main Street
�\
"j) 'v L RQCim 1,00
m e1 as w avd "' j FFtt :
Northapton; MA 01060 uuoc so ra ? r �
phone 413 5F-12 0 Fax 413-587-1272
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
SECTION11 -SITE INFORMATION
1.1 Property Address: Thhs sectron to be cgmpl to ycffce
Sl Map Lot unr
r
Zone Overtay Qrstrrct
ElrrrStaDistfrct CB Drstnct
SECTION-2.-PROPERTY OWNERSHIP/AUTHORIZED'AGENT
2.1 Owner of Record: R t'
Name(Pri Current Mailing Address:
Telephone
Signature
2.2 Aut rized Agent:
bj owlo 11 CE-Itv. ,11 214 �t ��ir< 41JfU
Name(Print Current Mailing Address:
91 261, 3385_ Yb_?
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)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) Ci Check Number Q
This Section For Official Use Only
Date
Building Permit Number. Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
� m
File#BP-2005-0835
APPLICANT/CONTACT PERSON TRZCIENSKI JOHN D&SHANNON M
ADDRESS/PHONE 304 HATFIELD ST NORTHAMPTON
PROPERTY LOCATION 878 BURTS PIT RD
MAP 36 PARCEL 186 001 ZONE SR
THIS SECTION FOR OFFICIAL USE ONLY:
PERMIT APPLICATION CHECKLIST
ENCLOSED REQUIRED DATE
ZONING FORM FILLED OUT
Fee Paid
Building Permit Filled out
Fee Paid
Typeof Construction: REBUILD EXISTING PORCH&ADD 10 X 20 DECK
New Construction
Non Structural interior renovations
Addition to Existing
Accessory Structure
Building Plans Included•
Owner/Statement or License
3 sets of Plans/Plot Plan
THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON
INFORMATION 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 Stree ommission
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.
878 BURTS PTT RD BP-2005-0835
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 36- 186 CITY OF NORTHAMPTON
Lot: -001
Permit: Building
Category. BUILDING PERMIT
Permit# BP-2005-0835
Project# JS-2005-1159
Est. Cost: $6100.00
Fee: $50.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License:
Use Groin Homeowner as Contractor
Lot Size(sq. ft.): 31232.52 Owner: TRZCIENSKI JOHN D&SHANNON M
Zoning: SR Applicant: TRZCIENSKI JOHN D &SHANNON M
AT: 878 BURTS PIT RD
Applicant Address: Phone: Insurance:
878 BURTS PIT RD
FLORENCEMA01062 ISSUED ON:3118105 0:00:00
TO PERFORM THE FOLLOWING WORK.-REBUILD EXISTING PORCH & ADD 10 X 20 DECK
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 Sienature:
FeeType• Date Paid: Amount:
Building 3/18/05 0:00:00 $50.00
212 Main Street,Phone(413)587-1240,Fax: (413)587-1272
Building Commissioner-Anthony Patillo